Hospital Wing AS350B3 accident in Tennessee
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So, in short, someone has to make that decision and sometimes that decision is right sometimes wrong.It is not a perfect system but it is the best we have, to date.
(The above includes military support including special ops, search and rescue, Casevac, Corporate, VIP, Police, over a period of 36 years).
I take it this was yet another accident involving a "VFR only" machine? Being flown in conditions that would have been more safely flown in an IFR equipped one, namely capable of being climbed to MSA when Night VFR was no longer possible.
I've flown VFR machines at night, some of them "floppy stick-ers". I trained on them, and was trained by the military to fly them on instruments. The last one I flew was originally SAS equipped but was stripped out so that police equipment could be carried instead.
These days I wouldn't accept a job requiring me to. No problem in UK, because legislation has outlawed it here, after previous high profile accidents
The answer to this slaughter? Use IFR equipped machines for an IFR job, or any job which has the possibility of becoming IFR. Train the crews to use them and keep them current. Take away the existing pressure to launch due to the no fly= no cash basis.
I keep banging on about this and make no excuses for doing so. I have personally experienced the aftermath of a number of accidents; just one accident is one too many. To keep losing people for the same basic reason is almost insane. The root cause of many of these EMS accidents is the requirement to make a profit.
In my country where there are a lot and I mean a lot of islands, we had three EMS crashes in a two years period. Immediately after each accident, the ambulance flights using helicopters dropped dramatically only to raise few months later. I am not sure it is relevant but maybe fewer flights means by definition fewer accidents?
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Rwy in Sight
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Provided you choose to "no go" on the correct occasions, how could it fail to have a significant effect?
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Shy torque, having spent three years flying an unstabilsed AS355 for Night HEMs in UK (prior to JAR-OPS), I think you are hitting the nail on the head. For me the decision to launch, continue or land in a filed and wait was based solely on the ongoing safety of the flight. We, and the unit, were fully funded for the fiscal year to provide a healthy number of flight and training hours.
My decision always final and always supported by my crew and the Ambulance Service Control.
I cannot imagine how this must translate when the flight is already begun, dollars being burned already and the safety margins start to compress.
It is in our nature to try our very best to get the mission done especially when it involves people at the other end who may desperately need our services. The only real protection possible is to legislate AND remove the financial pressure.
The free market economics do not blend well in this area of our industry.
I wish the families of those affected well and hope they can find some comfort in the fact that there loved ones lost their lives in pursuit of a greater cause.
DB
My decision always final and always supported by my crew and the Ambulance Service Control.
I cannot imagine how this must translate when the flight is already begun, dollars being burned already and the safety margins start to compress.
It is in our nature to try our very best to get the mission done especially when it involves people at the other end who may desperately need our services. The only real protection possible is to legislate AND remove the financial pressure.
The free market economics do not blend well in this area of our industry.
I wish the families of those affected well and hope they can find some comfort in the fact that there loved ones lost their lives in pursuit of a greater cause.
DB
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Shy Torque,
You misunderstand.The decision was not about going or not going.For the most part that is still the purview of the PIC.This was about the decision to use or not to use a helicopter to transfer a patient. That decision still remains with the physicians or the ambulance crew on the ground at the scene of an accident.Sometimes, people with hangnails have been flown and sometimes people who desperately needed a swift transportation were left to die or endure the ride to the hospital.Hence my comment about right and wrong decisions.
As for the rest of your comments, I could not agree more.
Alt 3.
You misunderstand.The decision was not about going or not going.For the most part that is still the purview of the PIC.This was about the decision to use or not to use a helicopter to transfer a patient. That decision still remains with the physicians or the ambulance crew on the ground at the scene of an accident.Sometimes, people with hangnails have been flown and sometimes people who desperately needed a swift transportation were left to die or endure the ride to the hospital.Hence my comment about right and wrong decisions.
As for the rest of your comments, I could not agree more.
Alt 3.
How can operational tasking/scheduling/prioritisation be responsible for actual flight safety? Isn't one the responsibility of an operations director/manager/controller and the other the responsibility of the pilot in command of the aircraft?
FAR Part 135 which all HEMES Operations in the USA must comply with, require Operational Control by the Operator in addition to any responsibility and duties required of the Pilot.
Enforcement of that Requirement by the FAA, after way too long, went a long way in reducing the frequency of EMS Helicopter Fatal Accidents.
To answer your question.....in the USA....we see flight safety as being a shared responsibility to include Dispatch Authority.
Rotor & Wing Magazine :: New Helicopter EMS Rules: What it Means for Public Operators
Last edited by SASless; 1st Nov 2013 at 11:48.
"Just a pilot"
Yes, as a rule, the PIC is the final authority as to accepting a dispatch request in USA HEMS operations. There are institutional and personal forces that could affect a PIC in taking the decision:
Revenue generated by transports completed is a clear and obvious issue in a 'for profit' operation, as is the 'rescue hero' syndrome. Many programs act to minimize these as much as possible, with varying effectiveness. But my experience is that pilots are there to fly and preventing a mistake from that mindset is a serious challenge.
Some programs require documentation of weather and other issues that prevent a transport being taken/completed. Adverse pressures, intentional and otherwise, are obvious. Generating data for management needs to be completely separated from the go/no-go.
I'm sticking my head up to draw fire, but the 'three to go' rule involves untrained and unqualified personnel, and occasionally, other agendas. This can put the absolute authority and responsibility for the decision in many hands. The idea is that any objection to a decision of dispatch will be towards the most conservative and safest action, but it's not always so. "Can't you/couldn't you do this, that or the other thing" discussions do occur and one should reasonably expect that to color the process.
I understand the operational control issue. I also see it as a potential dilution of responsibility- "If Op Con approves, it's probably alright".
To be clear, there's no reason to suspect any of these issues affected this event.
Revenue generated by transports completed is a clear and obvious issue in a 'for profit' operation, as is the 'rescue hero' syndrome. Many programs act to minimize these as much as possible, with varying effectiveness. But my experience is that pilots are there to fly and preventing a mistake from that mindset is a serious challenge.
Some programs require documentation of weather and other issues that prevent a transport being taken/completed. Adverse pressures, intentional and otherwise, are obvious. Generating data for management needs to be completely separated from the go/no-go.
I'm sticking my head up to draw fire, but the 'three to go' rule involves untrained and unqualified personnel, and occasionally, other agendas. This can put the absolute authority and responsibility for the decision in many hands. The idea is that any objection to a decision of dispatch will be towards the most conservative and safest action, but it's not always so. "Can't you/couldn't you do this, that or the other thing" discussions do occur and one should reasonably expect that to color the process.
I understand the operational control issue. I also see it as a potential dilution of responsibility- "If Op Con approves, it's probably alright".
To be clear, there's no reason to suspect any of these issues affected this event.
Last edited by Devil 49; 1st Nov 2013 at 13:23.
I used the Single "No!" method when deciding to go or not. If any member of the Crew said "No!" it was enough to call it and head for the Coffee Pot.
Even if the Crew said "Go!" and I decided for any reason not to go....the answer was "No Go!". Once I made that call....there was no altering it no matter who argued or whatever reason was given.
If the weather improved or some other measurable factor changed to allow the flight....then I would change my decision but it was my call...my responsibility....and most importantly....my LIABILITY!
I did not give a stuff about numbers of flights made, the profitability of the operation, the condition of the patient or the desires of the Operator, Hospital, or Med Crew.....my decisions were made on the FAR's, SOP's, Base Policies, my personal limits, and the existing weather and other factors that pertained to being able to make the flight safely and efficiently.
Our Mission Statement said something along the lines of "....to provide a Safe, Efficient, and Professional Medical Transportation Service...." and that is all we were obliged to do.
Heroics was not part of the pay check (cheque).
Even if the Crew said "Go!" and I decided for any reason not to go....the answer was "No Go!". Once I made that call....there was no altering it no matter who argued or whatever reason was given.
If the weather improved or some other measurable factor changed to allow the flight....then I would change my decision but it was my call...my responsibility....and most importantly....my LIABILITY!
I did not give a stuff about numbers of flights made, the profitability of the operation, the condition of the patient or the desires of the Operator, Hospital, or Med Crew.....my decisions were made on the FAR's, SOP's, Base Policies, my personal limits, and the existing weather and other factors that pertained to being able to make the flight safely and efficiently.
Our Mission Statement said something along the lines of "....to provide a Safe, Efficient, and Professional Medical Transportation Service...." and that is all we were obliged to do.
Heroics was not part of the pay check (cheque).
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SASless, we have always sung off the same hymn sheet in this matter. Sadly, it would appear that not all do, despite these ongoing and similar HEMS accidents.
With regard to the use of unstabilised VFR machines - any mission may launched having ticked all the right boxes (i.e. VFR achievable & maintainable, based on the met. information available at the time) but the forecast may of course be wrong.
That is when the real danger comes - does the pilot press on in marginal conditions, hoping to fly through a shower/poor visibility - or does he turn back. In this situation it's the easiest thing in the world to totally lose situational awareness and aircraft orientation, it occurs in a few seconds.
With a correctly flown IFR machine (i.e. instrumentation and stabilisation, preferably an autopilot fitted) a couple of button pushes and the aircraft systems will unload the pilot from most of his dangerous workload (overload) and climb itself to a safe altitude, on a safe heading. Having done so, the pilot can make a decision based on what he now knows and sees in front of him. It may even be possible to continue IFR for a while and subsequently let down back into VFR. If not, at least the aircraft and occupants are safe.
I know the stock answer to this - the industry can't do it because it can't afford it. As the old saying goes, "If you think flight safety is expensive, try having an accident".
With regard to the use of unstabilised VFR machines - any mission may launched having ticked all the right boxes (i.e. VFR achievable & maintainable, based on the met. information available at the time) but the forecast may of course be wrong.
That is when the real danger comes - does the pilot press on in marginal conditions, hoping to fly through a shower/poor visibility - or does he turn back. In this situation it's the easiest thing in the world to totally lose situational awareness and aircraft orientation, it occurs in a few seconds.
With a correctly flown IFR machine (i.e. instrumentation and stabilisation, preferably an autopilot fitted) a couple of button pushes and the aircraft systems will unload the pilot from most of his dangerous workload (overload) and climb itself to a safe altitude, on a safe heading. Having done so, the pilot can make a decision based on what he now knows and sees in front of him. It may even be possible to continue IFR for a while and subsequently let down back into VFR. If not, at least the aircraft and occupants are safe.
I know the stock answer to this - the industry can't do it because it can't afford it. As the old saying goes, "If you think flight safety is expensive, try having an accident".
Last 2 posts... Gold.
It really is that simple.
"....to provide a Safe, Efficient, and Professional Medical Transportation Service...." This sums it up...
That's all we are doing. Not saving the world, just moving a person from A to B who requires medical attention.
VFR single will do this fine with limits, IFR twin will give more options, however the FINAL decision rests with the PIC... not the Flt Nurse, not the Doctor, Base Manager, Etc... the PILOT.
As the pilot, are you comfortable launching based on available information, and conditions? fine. Current conditions outside your/aircraft ability... then simply No.
Doesn't matter if you NVG, IFR, Twin, blah blah... it is either safe to go, based on current information, or it is not...
In any event, if it's turning pear-shaped, then just land... overly simplistic, not really. We apply this to other types of helicopter flying don't we...?
It really is that simple.
"....to provide a Safe, Efficient, and Professional Medical Transportation Service...." This sums it up...
That's all we are doing. Not saving the world, just moving a person from A to B who requires medical attention.
VFR single will do this fine with limits, IFR twin will give more options, however the FINAL decision rests with the PIC... not the Flt Nurse, not the Doctor, Base Manager, Etc... the PILOT.
As the pilot, are you comfortable launching based on available information, and conditions? fine. Current conditions outside your/aircraft ability... then simply No.
Doesn't matter if you NVG, IFR, Twin, blah blah... it is either safe to go, based on current information, or it is not...
In any event, if it's turning pear-shaped, then just land... overly simplistic, not really. We apply this to other types of helicopter flying don't we...?
Standardization and Autopilots
SASLess, Shy torque and Big Mike make very valid points. I have a slightly different slant in addition to their comments. As a new guy to EMS eleven years ago I made a concerted effort to standardize my approach to the flights. All flights day or night were flown to a standard profile established by myself. This entailed a takeoff and climb to a standard altitude. Most flights were flown at two to three thousand feet AGL. If I didn’t have the weather to insure terrain and cloud clearances, I DID NOT go. This was really easy in areas without local weather reporting because I was the weatherman and could not be disputed. One unnamed regional manager attempted a comment on one of my no-go decisions but his comments became just background noise to the TV in the base quarters. My number of rejected flights was not any greater than any of my contemporaries in the region
In addition, having flown SPIFR I became very attached to the autopilot. Once again standardization kicked in. Day/night VFR or IFR the autopilot was always engaged shortly after takeoff and was not disengaged until descending for landing. This experience makes me believe that all EMS ships, single or twin should have an autopilot. Autopilots don’t care if the ship is in VMC or IMC it just continues to fly the machine. IIMC procedures are reduced to turning a heading knot and calling for help.
In addition, having flown SPIFR I became very attached to the autopilot. Once again standardization kicked in. Day/night VFR or IFR the autopilot was always engaged shortly after takeoff and was not disengaged until descending for landing. This experience makes me believe that all EMS ships, single or twin should have an autopilot. Autopilots don’t care if the ship is in VMC or IMC it just continues to fly the machine. IIMC procedures are reduced to turning a heading knot and calling for help.
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I wish we could run this thread in parallel with the 332 ditching thread. These 2 threads if read together to me defines the ultimate human factor in all the debates. On this thread we want automation to stop the accidents cause we dont have it, in the 332 thread theres a lot of critisism to automation and how its used when and how and type because we had automation! So, 2 accidents. Both lets simplify it to CFIT? 1 no automation so the solution is get it! 1 Full 4 axis fitted so the solution is some wants less automation, more training, better automation............... So it never ends?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
I did as Jack describes.....every flight was set up as though it were an IFR flight....frequencies set, heading bug set, course set, and when available Autopilot used. All charts, maps, approach plates arranged and ready.
Scene Flights to off airport destinations got treated as though they were to the nearest IFR Airport. Fueling flights whenever possible were Instrument Approaches to the Airport using a published approach to minimums....some hand on...some hand off depending upon the machine.
Even in a VFR Only Machine with no SAS......just in case the worst case scenario occurred.
One hint of un-foreceast weather or a deterioration of existing weather and it was find a Safe Haven time.
IIMC is a KILLER even if you are well prepared......un-prepared and the odds become almost certain you become a topic of discussion here and other places.
VP,
You miss the point of both discussions if you think each thread contradicts the other.
Automation is not the issue in either thread.
Proper use of Automation is.
Used properly in an EMS Helicopter....it can save your life.
Used improperly (or not used at all) and you can find yourself explaining yourself to a much higher authority.
Scene Flights to off airport destinations got treated as though they were to the nearest IFR Airport. Fueling flights whenever possible were Instrument Approaches to the Airport using a published approach to minimums....some hand on...some hand off depending upon the machine.
Even in a VFR Only Machine with no SAS......just in case the worst case scenario occurred.
One hint of un-foreceast weather or a deterioration of existing weather and it was find a Safe Haven time.
IIMC is a KILLER even if you are well prepared......un-prepared and the odds become almost certain you become a topic of discussion here and other places.
VP,
You miss the point of both discussions if you think each thread contradicts the other.
Automation is not the issue in either thread.
Proper use of Automation is.
Used properly in an EMS Helicopter....it can save your life.
Used improperly (or not used at all) and you can find yourself explaining yourself to a much higher authority.
Last edited by SASless; 3rd Nov 2013 at 10:23.
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I wish we could run this thread in parallel with the 332 ditching thread. These 2 threads if read together to me defines the ultimate human factor in all the debates. On this thread we want automation to stop the accidents cause we dont have it, in the 332 thread theres a lot of critisism to automation and how its used when and how and type because we had automation! So, 2 accidents. Both lets simplify it to CFIT? 1 no automation so the solution is get it! 1 Full 4 axis fitted so the solution is some wants less automation, more training, better automation............... So it never ends?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
Helicopter IFR is safe.
Blurring the two, or attempting one when the other is appropriate is what is UNSAFE.
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On this thread we want automation to stop the accidents cause we dont have it, in the 332 thread theres a lot of critisism to automation and how its used when and how and type because we had automation! So, 2 accidents. Both lets simplify it to CFIT? 1 no automation so the solution is get it! 1 Full 4 axis fitted so the solution is some wants less automation, more training, better automation............... So it never ends?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
Looking at the North Sea the last 5 years, I dont think its going to be as simple as IFR machines and the accidents will go away? The reasoning will just change and as per the 332 thread we come close to contradicting ourselves in the solution given simply of IFR machine?
On the 332 thread some are going on about better training/awareness of automated systems and understanding how they work which, you would think, would be standard. But, what if (for argument's sake) the automation fails, then what? Monitoring attitude, altitude, airspeed and heading should, you would think, be a fairly basic and frequent practice (especially on approach). But this comes down to personal discipline, initially through training and thereafter through ongoing personal subscription to the lessons learnt from that training, but in this case not in relation to the intricacies of automation but rather the basics of flying.
In the same way with this accident (assuming we are talking about CFIT) a skilled/disciplined pilot flying a single pilot scenario will ensure he/she understands the boundaries of their own and their aircraft's limitations, identify a healthy buffer between the periphery of those limitations and where they practice their operational flying, and then enforce this separation with discipline based on an appreciation that this buffer is a prerequisite to basic safety.
