A109S HEMS down in Portugal
In the American Helicopter EMS industry.....the Federal Air Regulations (FAR's) divide operations into three Parts.....Part 91 (non-commercial/private), Part 135 (Air Taxi), and Part 121 (Airlines).
Weather standards are much stricter for Part 135 Ops than under Part 91, and many EMS Operators could revert to Part 91 from Part 135 when there was not a Patient/Passenger onboard when the Operator owned the aircraft and directly employed the Pilot and Med Crew.
That facilitated returning to Base in worse weather after dropping off a patient.
It also provided the cause for a much higher accident rate than for operating under the more strict Part 135 Rules.
The similarity to that situation to this one re operating in definitely adverse weather at night under VFR is worth thinking about.
It is not the Rules that get you....but rather the decision to put yourself at risk in plainly dangerous weather particularly at night.
Surely there was a Bed and Breakfast, Hotel, or place to bed down for the night where the helicopter had landed safely with the patient.
The difference in accident rates for Day versus Night CFIT accidents is quite significant.
The US Helicopter EMS Industry proved that in spades.
Weather standards are much stricter for Part 135 Ops than under Part 91, and many EMS Operators could revert to Part 91 from Part 135 when there was not a Patient/Passenger onboard when the Operator owned the aircraft and directly employed the Pilot and Med Crew.
That facilitated returning to Base in worse weather after dropping off a patient.
It also provided the cause for a much higher accident rate than for operating under the more strict Part 135 Rules.
The similarity to that situation to this one re operating in definitely adverse weather at night under VFR is worth thinking about.
It is not the Rules that get you....but rather the decision to put yourself at risk in plainly dangerous weather particularly at night.
Surely there was a Bed and Breakfast, Hotel, or place to bed down for the night where the helicopter had landed safely with the patient.
The difference in accident rates for Day versus Night CFIT accidents is quite significant.
The US Helicopter EMS Industry proved that in spades.
SASless I think (out of my head, don˛t have the report at hand) NTSB after special hearing about HEMS safety in 2009 put together a list of reccomendations and one of them was to prohibit reverting to Part 91 after drop-off of patient (return-to-base flight) but staying under Part 135. Don`t know what FAA did with that reccomendation later.
In EASA land I believe this is not possible - HEMS mission is completed when you RTB - staying under AOC-Commercial rules until return to base. But, HEMS WX limits are quite low.
At first glance it seems these unfortunate guys really pushed the weather - but what is really interesting (and potentially lifesaving information) would be the background that brought this crew to such decision.
In EASA land I believe this is not possible - HEMS mission is completed when you RTB - staying under AOC-Commercial rules until return to base. But, HEMS WX limits are quite low.
At first glance it seems these unfortunate guys really pushed the weather - but what is really interesting (and potentially lifesaving information) would be the background that brought this crew to such decision.
Last edited by hoistop; 21st Dec 2018 at 08:18.
The FAA was "forced" to adopt many of the recommended changes.
The Safety Record has improved as a result of those changes.
Also....the use of NVG's has increased greatly which has also had a very significant effect.
The point of my post was to point out far too many CFIT events occurred AFTER the patient was safely delivered to the Hospital and it was Crew only aboard the aircraft.
The Safety Record has improved as a result of those changes.
Also....the use of NVG's has increased greatly which has also had a very significant effect.
The point of my post was to point out far too many CFIT events occurred AFTER the patient was safely delivered to the Hospital and it was Crew only aboard the aircraft.
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The FAA was "forced" to adopt many of the recommended changes.
The Safety Record has improved as a result of those changes.
Also....the use of NVG's has increased greatly which has also had a very significant effect.
The point of my post was to point out far too many CFIT events occurred AFTER the patient was safely delivered to the Hospital and it was Crew only aboard the aircraft.
The Safety Record has improved as a result of those changes.
Also....the use of NVG's has increased greatly which has also had a very significant effect.
The point of my post was to point out far too many CFIT events occurred AFTER the patient was safely delivered to the Hospital and it was Crew only aboard the aircraft.
I cant help thinking that with all the resources available to us now, it must be time to really start to develop RNAV/GNSS approaches, PINS, PBN and Low Level PBN routing networks for use in HEMS throughout EASA. All of this is already available and in use in some places. At the moment I feel the regulations are one of the greatest limitations to our safety. A mandated IFR rated crew, NVG, PBN and PINS network would surely be the next logical step to increasing safety. As a minimum, HEMS bases should have some form of IFR approach/recovery available as standard and crews the competence and confidence to regularly fly IFR. Until the authorities mandate this, it will not happen. It is easy to say “they shouldnt be there”, but the pressure on HEMS crews is not easy to define. Customers will all too often opt for he cheapest available option, assuming it is inherently safe, with nobody prepared or equipped to make the investment in safety until it is mandated. Unfortunately I am seeing all too often operations going the opposite direction, to reduce costs across the board. IFR costs. 2 crew costs. PINS costs. Who will pay when it is only optional? We are increasingly seeing the the trend for smaller airfields to close, control towers disappearing, and more centralisation to large airports in order to save cost. CFIT is the probably the highest risk to HEMS ops. We have the resources available technically to make it safer. We How many more accidents do the authorities need to prove this?
Avoid imitations
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It is a fantastic resource and tool to have, and certainly makes our routine ops far safer, however it should not be used as a way to get home in bad weather, under minima.
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Guys, we are in 2018, not in 1970......
We have all possible information's about the weather we face now, trough many different apps or anything else. You don't take-off at night for 100 NM ride without checking the weather....and what do you find? low IFR at your point of departure.
What do you expect to do in this case?
It doesn't matter what procedures your company has, you do not play Russian roulette there.
So, VFR flight was not possible from the start, since IFR is apparently complicated there, well, you don't go. And if you go and get caught which is what happened just after take-off, you request a clearance to go back to Porto, it is a full IFR airport.
In our life as a pilot, we will face difficult situations and decisions making can be complicated by many factors, but in no way, you try something like that.
I still don't understand how and why they did it because there is no way it was possible.
...and the NVG in bad weather is a killer....This is not what it is made for....
How many people have been killed with such a poor decision making, it is crazy.
We are responsible for the crew who is on board, we don't have the right to play and try, hoping it will work.
We have all possible information's about the weather we face now, trough many different apps or anything else. You don't take-off at night for 100 NM ride without checking the weather....and what do you find? low IFR at your point of departure.
What do you expect to do in this case?
It doesn't matter what procedures your company has, you do not play Russian roulette there.
So, VFR flight was not possible from the start, since IFR is apparently complicated there, well, you don't go. And if you go and get caught which is what happened just after take-off, you request a clearance to go back to Porto, it is a full IFR airport.
In our life as a pilot, we will face difficult situations and decisions making can be complicated by many factors, but in no way, you try something like that.
I still don't understand how and why they did it because there is no way it was possible.
...and the NVG in bad weather is a killer....This is not what it is made for....
How many people have been killed with such a poor decision making, it is crazy.
We are responsible for the crew who is on board, we don't have the right to play and try, hoping it will work.
Not a very detailed investigation required which explains the promptness of the preliminary report.
Got airborne in poor weather and hit a mast they didn't see until too late (if at all) - very avoidable HEMS accident...again!
Got airborne in poor weather and hit a mast they didn't see until too late (if at all) - very avoidable HEMS accident...again!
Preliminary begs more questions. Mast was 66m, terrain elevation at the tower was 370m, so they were at 435m/1400' ASL, crossing a ridge with a 100' to spare at night in reduced visibility at what, 130 knots???
Sounds like they departed the Massarelos hospital pad, needed fuel, and tried for Baltar which is enroute to Macedo. Only IFR recovery possible was Porto airport - nowhere else has an instrument approach. Once away from the coast the MOCA on a nearby airway is 7000' and off airways quadrant altitudes 8100.
Starting to sound a little like BlackRock. Some questionable SOP for a very routine local flight by an operator that thinks of itself in the big leagues. Regulations cannot anticipate every possible condition, there has to be an operational oversight and "attitude" that is impressed on the flight crew by the management of the AOC.
Bottom screenshot is Google Earth view of the tower in the flight direction at the 1400' eye elevation. Porto airport is north of Massarelos about 10 miles.
Fuel must have been an issue....thus even if IFR equipped, qualified, and current.....perhaps IFR was not a choice at all thus had to be attempted VMC.....and the reason for the high speed....TIME/Remaining Fuel?
Had they diverted to the south a bit an followed the road would there have been better visual clues like road traffic and lighting from homes and other structures?
Had they diverted to the south a bit an followed the road would there have been better visual clues like road traffic and lighting from homes and other structures?
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Or better SAS, (or less worse!) diverted just 2 miles north to be over the lights of Calvario town and then picked up the autoroute for a bit, for better VFR refs. But let's face it, this flight was just nuts - the weather was nowhere near ok for a safe night VFR transit, especially as the planned fuel stop at Baltar was at an elevation of 1000ft so higher still than most of the en-route terrain, so it should have looked pretty clear this was not going to work soon after launch. And with over 80nm to run to the Macedo destination with up to 3000ft hills/mountains to traverse en-route after the fuel stop, VFR had no chance, surely. I guess maybe the pilot thought he could get to Baltar VFR, then fuel up to go to Macedo IFR with reserves to return to Porto if he couldn't get down. Macedo was lower but still some hills around. Be interesting to see what the plan was. And if there was an IFR let down at Macedo he planned to use. Somehow doubt it.
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Or better still SAS and Rotorspeed, not set back out in the first place. Admittedly very easy to say with hindsight.
From the interim report although not sure where the met readings came from....
“Local atmospheric conditions were characterized by low ceilings, reported between 300 and 500 feet, with a horizontal visibility of only 1500m.”
What would the typical minimum weather be for dispatch for a VFR departure back to base in the Ops Manual for an AOC holder that had a HEMS approval?
From the interim report although not sure where the met readings came from....
“Local atmospheric conditions were characterized by low ceilings, reported between 300 and 500 feet, with a horizontal visibility of only 1500m.”
What would the typical minimum weather be for dispatch for a VFR departure back to base in the Ops Manual for an AOC holder that had a HEMS approval?
Was this another bit of magenta line following rather than assessing the terrain and going round instead of over it?
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There is a similar report posted on Aerossurance webpage regarding a BFU investigation of a S76 in a "near" CFIT situation....can't post link (yet), but supports the tendency noted by PlasticCabDriver of going low in bad weather. Worth a read in the context of CFIT.
