NTSB Hearing on Most Wanted: Improve the Safety of EMS Flights
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NTSB Hearing on Most Wanted: Improve the Safety of EMS Flights
This seems to deserve a thread in itself. A public hearing is due next month: NTSB - Safety of Helicopter Emergency Medical Services (HEMS) Operations
The NTSB statement on their most wanted (with my underlined emphasis) is below:
The NTSB statement on their most wanted (with my underlined emphasis) is below:
EMS aviation operations (conducted with either helicopters or fixed-wing aircraft) provide an important service to the public by transporting seriously ill patients or donor organs to emergency care facilities. The pressure to quickly conduct these operations in various environmental conditions (for example, in inclement weather, at night, and at unfamiliar landing sites for helicopter operations) continues to result in an increasing number of accidents.
Although the Safety Board issued recommendations in 2006 to improve EMS helicopter operations safety, 9 fatal helicopter EMS (HEMS) accidents occurred between December 2007 and October 2008, killing 35 people.
December 3, 2007: Whittier, Alaska – BK117
December 30, 2007: Cherokee, Alabama – Bell 206
February 5, 2008: South Padre Island, Texas – AS350
May 10, 2008: La Crosse, Wisconsin – EC135
June 8, 2008: Huntsville, Texas – Bell 407
June 29, 2008: Flagstaff, Arizona – Bell 407s
August 31, 2008: Greensburg, Indiana – Bell 206
September 28, 2008: District Heights, Maryland – AS365
October 15, 2008: Aurora, Illinois – Bell 222
The Safety Board is concerned that these types of accidents will continue to occur if a concerted effort is not made to improve the safety of emergency medical flights.
Specifically, the following actions would help to improve the safety of EMS flight operations:
(1) implementation of a flight risk evaluation program for EMS operators,
(2) establishment of formalized dispatch and flight-following procedures including up-to-date weather regulations,
(3) installation of terrain awareness and warning systems on aircraft, and
(4) conduct of all flights with medical personnel on board in accordance with stricter commuter aircraft regulations.
Summary of Action
In August 2004, the Federal Aviation Administration (FAA) convened a Helicopter Air Ambulance Accident Task Force to make recommendations to reduce HEMS accidents; however, in spite of numerous actions to address this issue through notices and guidance, little progress has been made by the FAA in improving the safety of EMS operations.
In 2005, the FAA issued three notices addressing HEMS safety; however, all three of the following notices expired after 1 year:
Notice N8000.293, “HEMS Operations,” contained information that FAA inspectors could provide to HEMS operators “for a review of pilot and mechanic decision-making skill, procedural adherence, and crew resource management.”
Notice N8000.301, “Operational Risk Assessment Programs for HEMS,” identified possible risks and dangers to flight crews and patients and encouraged aircraft EMS operators to promote the use of risk assessment models. The contents of N8000.301 have since been incorporated into Order 8900.1.
Notice N8000.307, “Special Emphasis Inspection Program for HEMS,” provided guidance to aviation safety inspectors for the examination of operational factors that were indentified as causal to EMS accidents such as operational control, safety culture development, and access to and use of weather information by flight crews, management, and in-flight communications specialists. (1)
In January 2006, the FAA issued revised guidance to inspectors regarding HEMS Operations Specifications (OpSpecs), amending the visual flight rule (VFR) weather requirements for HEMS operations, including consideration of the adverse affects of reduced ambient lighting at night and mountainous terrain (HBAT 06-01 Helicopter Emergency Services; OpSpec A021/A002 Revisions).
In January 2006, the Safety Board issued four safety recommendations concerning EMS flight safety. In June 2006, at the FAA’s request, the Radio Technical Commission for Aeronautics (RTCA) established a special committee to develop Helicopter TAWS (H-TAWS) standards. The RTCA, in March 2008, completed the development of a set of minimum operational performance standards for H-TAWS. The FAA anticipates publishing in early 2009 a Technical Standards Order that is based on the RTCA standards. The FAA will still need to consider rulemaking to require H-TAWS on EMS flights.
In August 2006, the FAA revised the Aeronautical Information Manual to provide guidance to pilots on assessing ambient lighting for night VFR operations and for off-airport/heliport landing zone operations.
Most recently, in May 2008, the FAA published Advisory Circular (AC) 120-96 regarding operations control centers (OCCs) for HEMS. The AC provides a list of tasks that should be completed by OCCs. Although the AC is responsive to Safety Recommendation A-06-14, the FAA has not yet incorporated a requirement for an OCC into HEMS regulations.
Despite the FAA’s efforts to improve EMS operations safety, the FAA has not imposed any requirements on aircraft EMS operators regarding flights conducted without patients on board, risk management, flight dispatch, or the use of such technology as TAWS or H-TAWS.
The FAA’s published notices simply constitute information that principle operations inspectors may provide to their operators and encourage the operators to incorporate.
The Safety Board concluded in its 2006 report (2) that the implementation of a flight risk evaluation before each mission, such as the action Notice N8000.301 proposed, would enhance the safety of EMS operations. N8000.301 expired in 2006; however, its contents were incorporated into FAA Order 8900.1. This inclusion was a positive step; however, the FAA still does not require EMS operators to take the actions recommended by the Board. The guidance provided by the FAA has not been widely adopted by EMS operators; accordingly, the Board is concerned that until the FAA institutes our recommended requirements, some EMS operators will continue to operate in an unsafe manner, which could lead to further accidents.
Actions Remaining
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board.
Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level.
Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.
Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations.
Safety Recommendations
A-06-12 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board. (Source: Special Investigation Report on Emergency Medical Services Operations.
[NTSB/SIR-06/01])
A-06-13 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-14 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Acceptable Response
Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-15 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
October 2008
National Transportation Safety Board, Special Investigation Report on Emergency Medical Services Operations (NTSB/SIR-06/01) (Washington, D.C.: NTSB, 2006).
National Transportation Safety Board, Special Investigation Report on Emergency Medical Services Operations (NTSB/SIR-06/01) (Washington, D.C.: NTSB, 2006).
Although the Safety Board issued recommendations in 2006 to improve EMS helicopter operations safety, 9 fatal helicopter EMS (HEMS) accidents occurred between December 2007 and October 2008, killing 35 people.
December 3, 2007: Whittier, Alaska – BK117
December 30, 2007: Cherokee, Alabama – Bell 206
February 5, 2008: South Padre Island, Texas – AS350
May 10, 2008: La Crosse, Wisconsin – EC135
June 8, 2008: Huntsville, Texas – Bell 407
June 29, 2008: Flagstaff, Arizona – Bell 407s
August 31, 2008: Greensburg, Indiana – Bell 206
September 28, 2008: District Heights, Maryland – AS365
October 15, 2008: Aurora, Illinois – Bell 222
The Safety Board is concerned that these types of accidents will continue to occur if a concerted effort is not made to improve the safety of emergency medical flights.
Specifically, the following actions would help to improve the safety of EMS flight operations:
(1) implementation of a flight risk evaluation program for EMS operators,
(2) establishment of formalized dispatch and flight-following procedures including up-to-date weather regulations,
(3) installation of terrain awareness and warning systems on aircraft, and
(4) conduct of all flights with medical personnel on board in accordance with stricter commuter aircraft regulations.
Summary of Action
In August 2004, the Federal Aviation Administration (FAA) convened a Helicopter Air Ambulance Accident Task Force to make recommendations to reduce HEMS accidents; however, in spite of numerous actions to address this issue through notices and guidance, little progress has been made by the FAA in improving the safety of EMS operations.
In 2005, the FAA issued three notices addressing HEMS safety; however, all three of the following notices expired after 1 year:
Notice N8000.293, “HEMS Operations,” contained information that FAA inspectors could provide to HEMS operators “for a review of pilot and mechanic decision-making skill, procedural adherence, and crew resource management.”
Notice N8000.301, “Operational Risk Assessment Programs for HEMS,” identified possible risks and dangers to flight crews and patients and encouraged aircraft EMS operators to promote the use of risk assessment models. The contents of N8000.301 have since been incorporated into Order 8900.1.
Notice N8000.307, “Special Emphasis Inspection Program for HEMS,” provided guidance to aviation safety inspectors for the examination of operational factors that were indentified as causal to EMS accidents such as operational control, safety culture development, and access to and use of weather information by flight crews, management, and in-flight communications specialists. (1)
In January 2006, the FAA issued revised guidance to inspectors regarding HEMS Operations Specifications (OpSpecs), amending the visual flight rule (VFR) weather requirements for HEMS operations, including consideration of the adverse affects of reduced ambient lighting at night and mountainous terrain (HBAT 06-01 Helicopter Emergency Services; OpSpec A021/A002 Revisions).
In January 2006, the Safety Board issued four safety recommendations concerning EMS flight safety. In June 2006, at the FAA’s request, the Radio Technical Commission for Aeronautics (RTCA) established a special committee to develop Helicopter TAWS (H-TAWS) standards. The RTCA, in March 2008, completed the development of a set of minimum operational performance standards for H-TAWS. The FAA anticipates publishing in early 2009 a Technical Standards Order that is based on the RTCA standards. The FAA will still need to consider rulemaking to require H-TAWS on EMS flights.
In August 2006, the FAA revised the Aeronautical Information Manual to provide guidance to pilots on assessing ambient lighting for night VFR operations and for off-airport/heliport landing zone operations.
Most recently, in May 2008, the FAA published Advisory Circular (AC) 120-96 regarding operations control centers (OCCs) for HEMS. The AC provides a list of tasks that should be completed by OCCs. Although the AC is responsive to Safety Recommendation A-06-14, the FAA has not yet incorporated a requirement for an OCC into HEMS regulations.
Despite the FAA’s efforts to improve EMS operations safety, the FAA has not imposed any requirements on aircraft EMS operators regarding flights conducted without patients on board, risk management, flight dispatch, or the use of such technology as TAWS or H-TAWS.
The FAA’s published notices simply constitute information that principle operations inspectors may provide to their operators and encourage the operators to incorporate.
The Safety Board concluded in its 2006 report (2) that the implementation of a flight risk evaluation before each mission, such as the action Notice N8000.301 proposed, would enhance the safety of EMS operations. N8000.301 expired in 2006; however, its contents were incorporated into FAA Order 8900.1. This inclusion was a positive step; however, the FAA still does not require EMS operators to take the actions recommended by the Board. The guidance provided by the FAA has not been widely adopted by EMS operators; accordingly, the Board is concerned that until the FAA institutes our recommended requirements, some EMS operators will continue to operate in an unsafe manner, which could lead to further accidents.
Actions Remaining
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board.
Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level.
Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.
Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations.
Safety Recommendations
A-06-12 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require all EMS operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board. (Source: Special Investigation Report on Emergency Medical Services Operations.
[NTSB/SIR-06/01])
A-06-13 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require all EMS operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-14 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Acceptable Response
Require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
A-06-15 (FAA)
Issued: February 7, 2006
Added to the Most Wanted List: 2008
Status: Open—Unacceptable Response
Require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. (Source: Special Investigation Report on Emergency Medical Services Operations. [NTSB/SIR-06/01])
October 2008
National Transportation Safety Board, Special Investigation Report on Emergency Medical Services Operations (NTSB/SIR-06/01) (Washington, D.C.: NTSB, 2006).
National Transportation Safety Board, Special Investigation Report on Emergency Medical Services Operations (NTSB/SIR-06/01) (Washington, D.C.: NTSB, 2006).
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In my opinion the only way to solve this problem is to make the direct managers much more personally responsible for the actions of their crews. If it can be shown that the pilot of the Evergreen aircraft (just an example, not meant to single this one accident out) was not properly trained in the use of NVG's, and that he was expected to use the NVG's then pull the Chief Pilots certificate for at least one year. Pull the DO's certificate for at least 6 months, AND do not allow him to act as a DO or any managment position for any certificate holder for one year. Do something this simple and you would be amazed at how fast training programs are brought up to date and oversight becomes commonplace. Hit managment in the wallet and things change!!
You can require any equipment combinations that you can imagine but if decision making is not enforced, if "get it done" attitudes are the norm, preventable accidents will continue to occur with regularity.
You can require any equipment combinations that you can imagine but if decision making is not enforced, if "get it done" attitudes are the norm, preventable accidents will continue to occur with regularity.
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Here's an improvement:
Reduce the number of EMS aircraft from the current (ridiculous) number of, what, 800? to something like 200, strategically placed aircraft that are not in competition with each other to fly every flippin' ankle fracture but are only used when there's a real medical need.
Et voila! Accident rate cut by 75 percent.
Reduce the number of EMS aircraft from the current (ridiculous) number of, what, 800? to something like 200, strategically placed aircraft that are not in competition with each other to fly every flippin' ankle fracture but are only used when there's a real medical need.
Et voila! Accident rate cut by 75 percent.
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Gomer, if you think I'm joking -I'm not.
The accident rate in the US -in absolute terms- is at least partially a function of the high number of hours flown, not just a function of poorer training or less capable aircraft in comparison to, say, Europe. In fact I'm willing to bet that in relative terms the accident rate of European night and day VFR EMS aircraft per flight hour is about on a par with the American rate.
Any EMS program worldwide can benefit from improved training; EGPWS; NVG; Radalt; TAWS etc. etc. I mean, duh!
But any kind of comprehensive review of EMS safety has to include a good long look at the way the entire EMS helicopter system is structured, and the way this structure contributes to dozens and dozens of helicopters being in the air every day at all hours, flying everything from traumatic amputations to bruised ankles.
Hell, maybe we'll collectively conclude that having 800 EMS helicopters is worth it in terms of reduced mortality rates of patients flown versus patients transported by road. But if that's the conclusion then maybe we should just accept the occasional accident and shut up about it.
The accident rate in the US -in absolute terms- is at least partially a function of the high number of hours flown, not just a function of poorer training or less capable aircraft in comparison to, say, Europe. In fact I'm willing to bet that in relative terms the accident rate of European night and day VFR EMS aircraft per flight hour is about on a par with the American rate.
Any EMS program worldwide can benefit from improved training; EGPWS; NVG; Radalt; TAWS etc. etc. I mean, duh!
But any kind of comprehensive review of EMS safety has to include a good long look at the way the entire EMS helicopter system is structured, and the way this structure contributes to dozens and dozens of helicopters being in the air every day at all hours, flying everything from traumatic amputations to bruised ankles.
Hell, maybe we'll collectively conclude that having 800 EMS helicopters is worth it in terms of reduced mortality rates of patients flown versus patients transported by road. But if that's the conclusion then maybe we should just accept the occasional accident and shut up about it.
Foggy hits the nail on the head....do the senior management attend the funerals even?
Perhaps we should just shut up and get on with the job....after all you cannot be a hero if no one is dying!
I am like Will Rogers....."We can't all be Heroes....someone has to sit on the curb and applaud as they parade by!"
Perhaps we should just shut up and get on with the job....after all you cannot be a hero if no one is dying!
I am like Will Rogers....."We can't all be Heroes....someone has to sit on the curb and applaud as they parade by!"
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SASless
Yes, senior management do attend funerals - no idea how many, but I've fortunately/unfortunately seen it. For what reason/s other than to limit legal exposure would be a rather cynical viewpoint, but it does come to mind, and what is taught to possibly minimize operator financial liability.
Amazing how everyone these days is a hero - I've only met one real such person in my lifetime. The rest of them were just doing their job! I think this hero stuff is just a fascination with adrenalin.
Accountability is a big deal, the more the merrier, in the direction of the shakers who put the movers in harm's way.
Seems we have exercised the heads-down approach to fixing HEMS for far too long - you know, all the IHST, FAA, NTSB, HAI and voluntary operator sponsored bandaids, etc.
How about the tails-up approach - i.e. how many tails are wagging the pilot-dog to do flights that shouldn't be done? How many flights are taken that don't hardly qualify for an ambulance because the first responders on-scene want to dump the patient on to a helo crew so the former can get back to barracks and off for the day? Don't think it doesn't happen? Do the homework. How many flights actually reduce mortaility or morbidity? I bet the numbers would be a shocker, excepting possibly in the cost of morbidity category and timely transport to a surgeon with an open operating room. How many pilots do flights because they really don't want to get that nagging email from the boss pointing out his/her status as the operation's pilot with the lowest completion rate? How about the pilot who has maintenance up his tail pipe every time he writes up a discrepancy so the straw breaks an off he/she goes with a defective AHRS in to a black hole. And on it goes with the things HEMS pilots have in the back of their minds just prior to saying yes, or no, to that ill-fated flight.
WIII
Yes, senior management do attend funerals - no idea how many, but I've fortunately/unfortunately seen it. For what reason/s other than to limit legal exposure would be a rather cynical viewpoint, but it does come to mind, and what is taught to possibly minimize operator financial liability.
Amazing how everyone these days is a hero - I've only met one real such person in my lifetime. The rest of them were just doing their job! I think this hero stuff is just a fascination with adrenalin.
Accountability is a big deal, the more the merrier, in the direction of the shakers who put the movers in harm's way.
Seems we have exercised the heads-down approach to fixing HEMS for far too long - you know, all the IHST, FAA, NTSB, HAI and voluntary operator sponsored bandaids, etc.
How about the tails-up approach - i.e. how many tails are wagging the pilot-dog to do flights that shouldn't be done? How many flights are taken that don't hardly qualify for an ambulance because the first responders on-scene want to dump the patient on to a helo crew so the former can get back to barracks and off for the day? Don't think it doesn't happen? Do the homework. How many flights actually reduce mortaility or morbidity? I bet the numbers would be a shocker, excepting possibly in the cost of morbidity category and timely transport to a surgeon with an open operating room. How many pilots do flights because they really don't want to get that nagging email from the boss pointing out his/her status as the operation's pilot with the lowest completion rate? How about the pilot who has maintenance up his tail pipe every time he writes up a discrepancy so the straw breaks an off he/she goes with a defective AHRS in to a black hole. And on it goes with the things HEMS pilots have in the back of their minds just prior to saying yes, or no, to that ill-fated flight.
WIII
The accident rate is not altered by removing operations only the number of accidents. When someone provides the accident rate, we can start to compare it to other world-wide figures.
It is a commonly held view that removing the night operations (at least those unaided) would reduce the accident rate.
Applying a realistic dispatch criteria might also reduce the accident rate.
However, all that is speculation until the JHSAT provides the analysis that can pinpoint the specific type/area of operations that results in unacceptable risk. Problem is that most accidents/incidents have a chain of causal links - some of which are complex and which may lay dormant for months or even years.
Most of what has been discussed here (and on other threads) points to a cultural issue which can only be addressed once there is acceptance that there is a problem.
Jim
It is a commonly held view that removing the night operations (at least those unaided) would reduce the accident rate.
Applying a realistic dispatch criteria might also reduce the accident rate.
However, all that is speculation until the JHSAT provides the analysis that can pinpoint the specific type/area of operations that results in unacceptable risk. Problem is that most accidents/incidents have a chain of causal links - some of which are complex and which may lay dormant for months or even years.
Most of what has been discussed here (and on other threads) points to a cultural issue which can only be addressed once there is acceptance that there is a problem.
Jim
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JimL
Agree, and thanks for the input.
It is amazing to watch a group of people within a HEMS culture when the subjective light bulb goes on (their point of recognition and acceptance they had a problem) concerning some macro type practice they had faith in which is proven incomplete, wrong, or not applicable, etc.
There is a certain smugness as to the simplicity of historical success amongst some HEMS cultures (to include first responders on the ground, dispatchers, etc.) operating without an incident or accident for an increasing period of years that grows and becomes more impenetrable right along with their weaknesses - to the point where a problem arises or a magic phrase catches someone's attention within the group. Hopefully it is a phrase that starts things going down safer operating paths.
I watched a HEMS operation practice a culture of avoidance. It was characterized by "don't do this, don't do that, don't, don't, don't" sort of orientation as to what they would or not undertake in flight operations. Their belief was that by doing so all incidents and accidents could be foreseen and would be avoided. What caught their attention was a phrase "you folks haven't scratched the surface of the anxieties available to yourselves in HEMS operations". This led to they wanting to know more about such things similar to your statement "most accidents/incidents have achain of causal links - some of which are complex and which may lay dormant for months or even years". They just never really thought there could be little insidious and slippery time bombs growing in the midst of their history and practices just ready to accumulate and/or align to cause a major problem they would have to deal with, without fail.
After the bulb went on the reviews began, more attention to real world requirements increased, confidence went up, and overall professional results became measureable.
We can be fascinated with technology and potential remedies such as autopilots, EGPWS, night vision, etc., as we are, but it would be far more useful to become fascinated with the frailty of our human systems and intereactions amongst all ourselves from company management, to dispatchers, ground first responders, maintenance, pilots, etc. in HEMS, first, before we take the leap to relying upon more expense and complication of the ever-increasing use of technology in this business.
Horse before the cart sort of thing.
Off box!
WIII
Agree, and thanks for the input.
It is amazing to watch a group of people within a HEMS culture when the subjective light bulb goes on (their point of recognition and acceptance they had a problem) concerning some macro type practice they had faith in which is proven incomplete, wrong, or not applicable, etc.
There is a certain smugness as to the simplicity of historical success amongst some HEMS cultures (to include first responders on the ground, dispatchers, etc.) operating without an incident or accident for an increasing period of years that grows and becomes more impenetrable right along with their weaknesses - to the point where a problem arises or a magic phrase catches someone's attention within the group. Hopefully it is a phrase that starts things going down safer operating paths.
I watched a HEMS operation practice a culture of avoidance. It was characterized by "don't do this, don't do that, don't, don't, don't" sort of orientation as to what they would or not undertake in flight operations. Their belief was that by doing so all incidents and accidents could be foreseen and would be avoided. What caught their attention was a phrase "you folks haven't scratched the surface of the anxieties available to yourselves in HEMS operations". This led to they wanting to know more about such things similar to your statement "most accidents/incidents have achain of causal links - some of which are complex and which may lay dormant for months or even years". They just never really thought there could be little insidious and slippery time bombs growing in the midst of their history and practices just ready to accumulate and/or align to cause a major problem they would have to deal with, without fail.
After the bulb went on the reviews began, more attention to real world requirements increased, confidence went up, and overall professional results became measureable.
We can be fascinated with technology and potential remedies such as autopilots, EGPWS, night vision, etc., as we are, but it would be far more useful to become fascinated with the frailty of our human systems and intereactions amongst all ourselves from company management, to dispatchers, ground first responders, maintenance, pilots, etc. in HEMS, first, before we take the leap to relying upon more expense and complication of the ever-increasing use of technology in this business.
Horse before the cart sort of thing.
Off box!
WIII
Get back up there WWIII....you are on a pretty good roll there.
My recollection of a point Nick Lappos tried to make that got glossed over in the past discussions we have had on this matter is the one he made about the effectiveness of our training system and the goals it sets out to meet. I agreed with Nick the current system uses a pretty odd matrix of elements that in the past seem not to have made an improvement in the safety record.
That falls right in line with what you are saying about the "human" element needs to be looked at first and in all probability will have the greatest positive effect for postive change.
If we don't know how to use our toys....both switchology and strategy....the toys will be just that and not provide that much benefit.
My recollection of a point Nick Lappos tried to make that got glossed over in the past discussions we have had on this matter is the one he made about the effectiveness of our training system and the goals it sets out to meet. I agreed with Nick the current system uses a pretty odd matrix of elements that in the past seem not to have made an improvement in the safety record.
That falls right in line with what you are saying about the "human" element needs to be looked at first and in all probability will have the greatest positive effect for postive change.
If we don't know how to use our toys....both switchology and strategy....the toys will be just that and not provide that much benefit.
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SASless and WWIII:
excellent points. We can all slice and dice the data to fit our own pet peeves (one of mine is autopilots and the lack thereof, and the lack of use thereof when fitted), but we need to really look at the training and information and a whole host of other factors before we start making any major changes.
I've started a series in Vertical about the differences between fixed wing airline operations and helicopters that has led down some unexpected paths. I hope it starts more discussion on the current situation.
excellent points. We can all slice and dice the data to fit our own pet peeves (one of mine is autopilots and the lack thereof, and the lack of use thereof when fitted), but we need to really look at the training and information and a whole host of other factors before we start making any major changes.
I've started a series in Vertical about the differences between fixed wing airline operations and helicopters that has led down some unexpected paths. I hope it starts more discussion on the current situation.
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Shawn and SASless
Paradigm shift comes to mind.
Yes, Nick has an eye for the start and finish of a race, and everything in-between. I bet flying that C/L Ringmaster or the like in many circles at a young age developed vision for completing the circle of effort to finish projects in grand fashion.
I like Toys, they are good. I like HEMS toys too, especially TCAS, EGPWS, Radar, XM-weather, cross talking UNS-1D FMS, or GNS530s in a pinch, and MLS, and SPZ 7600, and dual radalts, Full FADEC, with five full span MFDs, and the nice lady who announces when I'm approaching Vne, or "low height, low height" upon entering a somehwat dark hole at night to pick up a broken arm whilst the med crew announce "STOP STOP STOP" to which I respond "did you say STOP STOP STOP?"
Complex toys in a complex single pilot operating environment like HEMS can be good, but more often coupled to all the FAA matrices of decision making etc., high and low light factors, what the phase of the moon is going to be for the flight, the angle of the dangle of the cultural lighting, coupled to four octas or more inbound mid-altitude cloud layer over the last 1/3rd of the route (oh, bugger, excuse moi, wrong route, gotta start over), chart the route and make sure the very ancient and multiple MEL'd status rotary winged flying machine is X feet above all obstacles, coupled by late in preflight planning the on-scene commander hollering "where the *&^% is the helicopter, call YZX operator and GET ME A CHOPPER", followed by the inevitable med crew adrenalin level (truly an annoying drug) leading to obvious signs of 'get it going, will ya?' type fidgeting communications creating some level of confusion and frustration in Captain I'm An ACE's mental prioritization skills which morphs to the statement "to heck with it, let's get out the door, we'll sort this out enroute (yeah, sure - been there, got the T-shirt) we've got to keep the customer happy" but of course ACE still has to do a few phone calls to security to let them know (as well as every other uncle on the planet) they are out-the-door to do CofG calculations for entry to paperwork, take out heaters, untie the blades, do another walk around to hop in and do the 100 item checklist, sets the stage to encourage the differing layers of safety filtering Swiss cheese coming in to alignment to let the arrow through such that Captain Ace is right next to his/her first or next incident or accident. Any wonder why? Too many fingers in the pie?
The question is, who set up this mess? The shaker or the mover?
Some things are easy, some almost impossible, but focusing on ourselves working together in the field from the bottom up has got to be the start of realizing the solution to our abysmal accident rate in HEMS. It's obvious the route we've been on for the last 30 years, and at present, is just not the primal answer - good effort, no cigar.
With due respect I hope JHSAT and IHSAT or whatever top down approach we are presently pouring our lives in to comes to the same conclusion.
What's that? KISS? Never hear of it. Works everywhere else, especially the airlines, but let's just realize this is HEMS! This is emergency services, and we best be acting like it, so hurry up and get out there and save lives.
Yes, I'm cynical, and disappointed in all this HEMS stuff, but I'll keep plugging and maybe, just maybe, I'll be part of the solution and can then retire in peace.
WIII
Paradigm shift comes to mind.
Yes, Nick has an eye for the start and finish of a race, and everything in-between. I bet flying that C/L Ringmaster or the like in many circles at a young age developed vision for completing the circle of effort to finish projects in grand fashion.
I like Toys, they are good. I like HEMS toys too, especially TCAS, EGPWS, Radar, XM-weather, cross talking UNS-1D FMS, or GNS530s in a pinch, and MLS, and SPZ 7600, and dual radalts, Full FADEC, with five full span MFDs, and the nice lady who announces when I'm approaching Vne, or "low height, low height" upon entering a somehwat dark hole at night to pick up a broken arm whilst the med crew announce "STOP STOP STOP" to which I respond "did you say STOP STOP STOP?"
Complex toys in a complex single pilot operating environment like HEMS can be good, but more often coupled to all the FAA matrices of decision making etc., high and low light factors, what the phase of the moon is going to be for the flight, the angle of the dangle of the cultural lighting, coupled to four octas or more inbound mid-altitude cloud layer over the last 1/3rd of the route (oh, bugger, excuse moi, wrong route, gotta start over), chart the route and make sure the very ancient and multiple MEL'd status rotary winged flying machine is X feet above all obstacles, coupled by late in preflight planning the on-scene commander hollering "where the *&^% is the helicopter, call YZX operator and GET ME A CHOPPER", followed by the inevitable med crew adrenalin level (truly an annoying drug) leading to obvious signs of 'get it going, will ya?' type fidgeting communications creating some level of confusion and frustration in Captain I'm An ACE's mental prioritization skills which morphs to the statement "to heck with it, let's get out the door, we'll sort this out enroute (yeah, sure - been there, got the T-shirt) we've got to keep the customer happy" but of course ACE still has to do a few phone calls to security to let them know (as well as every other uncle on the planet) they are out-the-door to do CofG calculations for entry to paperwork, take out heaters, untie the blades, do another walk around to hop in and do the 100 item checklist, sets the stage to encourage the differing layers of safety filtering Swiss cheese coming in to alignment to let the arrow through such that Captain Ace is right next to his/her first or next incident or accident. Any wonder why? Too many fingers in the pie?
The question is, who set up this mess? The shaker or the mover?
Some things are easy, some almost impossible, but focusing on ourselves working together in the field from the bottom up has got to be the start of realizing the solution to our abysmal accident rate in HEMS. It's obvious the route we've been on for the last 30 years, and at present, is just not the primal answer - good effort, no cigar.
With due respect I hope JHSAT and IHSAT or whatever top down approach we are presently pouring our lives in to comes to the same conclusion.
What's that? KISS? Never hear of it. Works everywhere else, especially the airlines, but let's just realize this is HEMS! This is emergency services, and we best be acting like it, so hurry up and get out there and save lives.
Yes, I'm cynical, and disappointed in all this HEMS stuff, but I'll keep plugging and maybe, just maybe, I'll be part of the solution and can then retire in peace.
WIII
Last edited by WhirlwindIII; 20th Jan 2009 at 16:41.
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On a thread some time back, someone attached a paper by Sidney Dekker about the basic concept of safety.
In simple terms, he suggested that we should not think of flying as inherently safe and that an incident or accident has an active cause, but instead to think that flying is inherently dangerous and in fact it is the systems we adopt that prevent an incident or accident. When the system is not correct, or we do not action the system correctly, then failure has the opportunity to succeed, and we have an incident or accident.(OK, it goes deeper than that, but this message is what I took away from it).
Looking at the HEMS industry from this angle, and reading or listening to the stories about what is happening, it is often clear where the systems adopted are not appropriate to prevent failure from succeeding.
In simple terms, he suggested that we should not think of flying as inherently safe and that an incident or accident has an active cause, but instead to think that flying is inherently dangerous and in fact it is the systems we adopt that prevent an incident or accident. When the system is not correct, or we do not action the system correctly, then failure has the opportunity to succeed, and we have an incident or accident.(OK, it goes deeper than that, but this message is what I took away from it).
Looking at the HEMS industry from this angle, and reading or listening to the stories about what is happening, it is often clear where the systems adopted are not appropriate to prevent failure from succeeding.
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The NTSB sometimes issues recommendations without completely thinking them through, ISTM. The one requiring flight above all obstacles is a case in point. It just requires flying above all obstacles, but doesn't say how much lateral distance we have to check for obstacles. Do we have to account for every obstacle in the US, 100 miles on each side, or just the same lateral distance as vertical distance? We have no idea, but we are being required to comply, even though they don't say what we have to comply with. Too often the government, and private companies, just take knee-jerk actions so they can say they did something, whether it makes sense or not.
The TAWS software needs tweaking to be really usable. Bitchin' Betty gets really excited every time I try to land, demanding that I "PULL UP, PULL UP!!" because of terrain, when I know full well terrain is there, and I intend to land on it. Consequently, she gets shut up more than she really should, because everyone gets tired of the unnecessary bitchin'. TAWS is certainly a good idea, but poor implementation means it's not really that much help. Too much stuff really hasn't been thought through from the perspective of the pilot sitting in the seat, and it's just not possible to do this from an office seat, or even from the seat of an aircraft that's doing other things, but that's what we're getting.
The TAWS software needs tweaking to be really usable. Bitchin' Betty gets really excited every time I try to land, demanding that I "PULL UP, PULL UP!!" because of terrain, when I know full well terrain is there, and I intend to land on it. Consequently, she gets shut up more than she really should, because everyone gets tired of the unnecessary bitchin'. TAWS is certainly a good idea, but poor implementation means it's not really that much help. Too much stuff really hasn't been thought through from the perspective of the pilot sitting in the seat, and it's just not possible to do this from an office seat, or even from the seat of an aircraft that's doing other things, but that's what we're getting.
Whirlwind has been there and done that!
The truth that your post contains is way beyond descriptive of the real world of American EMS.
I had flashbacks reading your post!
Gosh....it is beer time already....need to peer into a brown bottle and congratulate myself upon taking up other employment!
The truth that your post contains is way beyond descriptive of the real world of American EMS.
I had flashbacks reading your post!
Gosh....it is beer time already....need to peer into a brown bottle and congratulate myself upon taking up other employment!
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TAWS / EGPWS has been developed for helicopter use. Blue Hawaiian got their system modified to provide very good information that was suitable for their operation. Not sure if anyone else has ever used that same format.
Why not?
I'm reminded of the comment from the Commanche team about the stated requirement to meet the handling qualities laid out in ADS-33. They said that they would make a helicopter that flew well, regardless of what ADS-33 said.
We need information that is useful to helicopter operations, (regardless of what a spec for TAWS / EGPWS says), that is quick and easy to set up, and gives us the information we need - not what some spec says it should.
But we need to have informed, technically savvy people specify what we should have. Folks who are knowledgeable about what can and should be done. Don't see too many of those around, unfortunately.
Why not?
I'm reminded of the comment from the Commanche team about the stated requirement to meet the handling qualities laid out in ADS-33. They said that they would make a helicopter that flew well, regardless of what ADS-33 said.
We need information that is useful to helicopter operations, (regardless of what a spec for TAWS / EGPWS says), that is quick and easy to set up, and gives us the information we need - not what some spec says it should.
But we need to have informed, technically savvy people specify what we should have. Folks who are knowledgeable about what can and should be done. Don't see too many of those around, unfortunately.
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Item from Aviation International News today
HEMS Crash Documents Reveal Varied, Complex Causes
Not surprisingly, there is no “magic bullet” solution to the spate of fatal helicopter emergency medical service (HEMS) crashes over the last two years. Rather, investigation documents, released by the NTSB Press Advisory late last week, reveal a complex mosaic of multi-level human and technology failures behind nine of these crashes in the past two years. Page upon page of interviews, transcripts and forms unveil myriad indirect and direct causes, including “helicopter shopping” by dispatchers–when one HEMS company rejected a flight, generally due to weather, they kept dialing until another operator accepted the flight. Other factors include pilots assigned, or voluntarily taking, excessive duty time; pilots flying into marginal weather or below safe performance envelopes; a pilot flying injured; and, in at least one case, a pilot with a vision restriction apparently flying without wearing his glasses. Organizational problems also loom large as at least contributory factors: morale problems; high personnel turnover; maintenance issues; old equipment; failure to install modern safety enhancements such as TCAS, TAWS and NVGs; and instrument-rated pilots flying IFR-equipped helicopters, but not being allowed to fly IFR under the terms of the operator’s Part 135 certificate.
HEMS Crash Documents Reveal Varied, Complex Causes
Not surprisingly, there is no “magic bullet” solution to the spate of fatal helicopter emergency medical service (HEMS) crashes over the last two years. Rather, investigation documents, released by the NTSB Press Advisory late last week, reveal a complex mosaic of multi-level human and technology failures behind nine of these crashes in the past two years. Page upon page of interviews, transcripts and forms unveil myriad indirect and direct causes, including “helicopter shopping” by dispatchers–when one HEMS company rejected a flight, generally due to weather, they kept dialing until another operator accepted the flight. Other factors include pilots assigned, or voluntarily taking, excessive duty time; pilots flying into marginal weather or below safe performance envelopes; a pilot flying injured; and, in at least one case, a pilot with a vision restriction apparently flying without wearing his glasses. Organizational problems also loom large as at least contributory factors: morale problems; high personnel turnover; maintenance issues; old equipment; failure to install modern safety enhancements such as TCAS, TAWS and NVGs; and instrument-rated pilots flying IFR-equipped helicopters, but not being allowed to fly IFR under the terms of the operator’s Part 135 certificate.