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US HEMS Accident

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US HEMS Accident

Old 18th Mar 2019, 00:55
  #101 (permalink)  
 
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Memory serves me we removed the Water Filters from the Barrel Pumps in the Winter up in Alaska.....two reasons....water becomes ice and jet fuel gets awfully thick and hard to pump by hand.

We are talking Temps of 0 degrees F and colder....down to like -45F.

I went South after I saw -50F on any OAT Gauge as I was a fair weather pilot.....and not a real Sourdough.

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Old 18th Mar 2019, 02:02
  #102 (permalink)  
 
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Icing in cold temps

Originally Posted by Outwest View Post
Don't let anyone ever tell you you can't have fog (ice fog) at -40C I have iced up badly at -40C, ice fog rising off the open sea in the Canadian arctic
Very true.

Strong winds = open leads = ice fog. Often you will see a "Moon Dog" associated with these conditions.

I have picked up heavy clear at -45C in the Lougheed Island area in November/December/January.

I experienced the same icing conditions in the Beaufort Sea on 212/61/76's every winter I flew there (8 years).
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Old 18th Mar 2019, 02:29
  #103 (permalink)  
 
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Originally Posted by megan View Post
Water can remain liquid down to -40°C. Then you can have ice fog which only forms under specific conditions; the humidity has to be near 100% as the air temperature drops to well below 0 °C (32 °F), allowing ice crystals to form in the air.
Well... I guess I'm just allowing my ignorance to shine brightly. Just a very lower-48 kind of guy.
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Old 18th Mar 2019, 07:35
  #104 (permalink)  
 
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Most aviation meteorology books with a section on icing will tell you about supercooled water droplets - ie those existing below 0 degrees C which can be found in temperatures as low as -40 degrees C, normally in cloud with lots of vertical movement.

However, it requires the absence of appropriate freezing nuclei in the atmosphere for the water to freeze onto.
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Old 18th Mar 2019, 09:57
  #105 (permalink)  
 
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Originally Posted by [email protected] View Post
Most aviation meteorology books with a section on icing will tell you about supercooled water droplets - ie those existing below 0 degrees C which can be found in temperatures as low as -40 degrees C, normally in cloud with lots of vertical movement.

However, it requires the absence of appropriate freezing nuclei in the atmosphere for the water to freeze onto.
I remember the "supercooled water droplets" and "condensation nuclei" questions but have never had any experiences related to it.
It was wayyy back in my head-noodle. I would guess it's pretty hard to find modern day sky that is not packed with condensation nuclei.
I was just searching for weather related reasons this HEMS crash could have happened. I know fast-forming fog could put a pilot in a
situation with no "out."
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Old 19th May 2020, 19:35
  #106 (permalink)  
 
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Radar and other data sources showed the helicopter, which was only certified to operate in visual flight conditions, flying mostly between 900 and 1,700 feet above ground level as it traversed the first of two bands of snow showers. During a second encounter with snow several minutes later, which would have significantly reduced visibility, the pilot made a left 180° turn in what investigators said was likely an effort to reverse course to an area of better visibility. For unknown reasons, the pilot failed to maintain altitude while making the turn and the helicopter collided with trees and then terrain in a heavily wooded area
A VFR helo trying to make a 180-degree turn in reduced visibility has a CFIT. Seems like I've heard that one before...

Helicopter Air Ambulance Operator’s Poor Safety Management, Inadequate Oversight Led to Fatal Crash

5/19/2020 WASHINGTON (May 19, 2020) — An air ambulance helicopter crash that killed three crew members was caused by the operator’s “inadequate management of safety,” which led to a pilot departing on a flight without a thorough preflight weather evaluation, the National Transportation Safety Board announced in a public meeting Tuesday.

The Bell 407 helicopter air ambulance, operated by Survival Flight, crashed in Zaleski, Ohio, Jan. 29, 2019, in deteriorating weather while enroute to pick up a patient for transport from one hospital to another. All three occupants – the pilot, flight nurse and flight paramedic – were killed in the accident.

“This accident was all but invited by the actions and culture of Survival Flight,” said NTSB Chairman Robert L. Sumwalt. “Unfortunately, we have seen yet another case of how a poor safety culture can lead to tragedy.”

Radar and other data sources showed the helicopter, which was only certified to operate in visual flight conditions, flying mostly between 900 and 1,700 feet above ground level as it traversed the first of two bands of snow showers. During a second encounter with snow several minutes later, which would have significantly reduced visibility, the pilot made a left 180° turn in what investigators said was likely an effort to reverse course to an area of better visibility. For unknown reasons, the pilot failed to maintain altitude while making the turn and the helicopter collided with trees and then terrain in a heavily wooded area.




(In this photo taken Aug. 7, 2018, the accident helicopter is positioned on the helipad at Mount Carmel East Hospital, Columbus, Ohio. Photo courtesy of The Columbus Dispatch.)

In post-accident interviews, current and former Survival Flight employees said there was pressure from management to operate flights in challenging conditions and to take flights that other helicopter air ambulance services turned down due to inclement weather.

The NTSB found pilots and operations staff of Survival Flight routinely failed to comply with preflight risk assessment procedures because such noncompliance had become “normalized” by Survival Flight’s deficient safety culture.

The NTSB also said the Federal Aviation Administration’s inadequate oversight of Survival Flight’s risk management program and the FAA’s failure to require helicopter air ambulance operators to have safety management systems contributed to the accident.

Investigators said the safety risks that existed at Survival Flight would likely have been identified and mitigated by a properly run safety management system, which could have prevented this crash.

In 2009 the NTSB recommended the FAA require all helicopter air ambulance operators to have safety management systems. The FAA didn’t adopt the recommendation – and the NTSB subsequently identified the lack of safety management systems as a factor in a string of additional fatal crashes. In 2016 the NTSB recommended that all on-demand aircraft operators, including helicopter air ambulances, be required to have safety management systems. That recommendation, which was reiterated three times between 2016 and 2020, was reiterated for a fourth time Tuesday.

“We keep asking that safety management systems be required of Part 135 operators because we keep seeing crashes the systems are designed to prevent,” said Sumwalt. “This has to change, and it is past time for the FAA to implement our recommendation.”

Improving the safety of Part 135 operations is on the NTSB’s Most Wanted List.

As a result of the investigation the NTSB made 14 new recommendations to the FAA, the National Weather Service and Survival Flight. The NTSB also reiterated four other recommendations previously issued to the FAA.

An abstract of the NTSB report, which includes the findings, probable cause and safety recommendations, is available at https://go.usa.gov/xvJ8A.

The complete text of the final report is expected to be published in the next few weeks. The accident docket, containing more than 2,600 pages of factual materials was opened Nov. 19, 2019; it is available at https://go.usa.gov/xvsha.
https://www.ntsb.gov/news/press-rele...R20200519.aspx
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Old 19th May 2020, 20:39
  #107 (permalink)  
 
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Seems like I've heard that one before..
...and before that and before that ad nauseam.
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Old 20th May 2020, 05:31
  #108 (permalink)  
 
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Maybe 'Survival Flight' should change their name
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Old 20th May 2020, 17:39
  #109 (permalink)  
 
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Seems like an accident waiting to happen. Does the FAA perform any oversight of HEMS operators? This accident comes down to this:

1. The information that 2 previous operators declined this flight was never passed to the accident operator/pilots.

2. Unacceptable behavior:

“When the accident pilot arrived at Base 14, she proceeded directly to the already-started helicopter and departed.”

“There was no record of the accident pilot receiving a weather briefing or 2 accessing any imagery on the weather application (Foreflight).”

“Additionally, neither pilot completed a preflight risk assessment for the flight, as required by Title 14 Code of Federal Regulations Part 135.617, and the evening shift pilot stated he expected the accident pilot to complete the assessment after she returned.” My italics.


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Old 20th May 2020, 18:41
  #110 (permalink)  
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As much as the threat to a regular paycheck is always a major consideration, there are very few HEMS accidents that can't be root caused back to poor airmanship. Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable risk. If (as a Captain) you are unable to do that, commercial flying may not be for you.
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Old 21st May 2020, 01:49
  #111 (permalink)  
 
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Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable risk
True in a perfect world Ti, but when normalisation of deviance is the SOP, and it's the company ethos, else you are subject to the highlighted part of the NTSB report below.
Survival Flight’s inconsistent compliance with standard operating procedures and regulations, combined with management’s procedural gaps in risk management, advertising of flights in lower weather minimums, pressure to complete flights, and punitive repercussions for safety decisions, were indicative of a poor safety culture at the company.

Probable Cause

The NTSB determines that the probable cause of this accident was Survival Flight’s inadequate management of safety, which normalized pilots’ and operations control specialists’ noncompliance with risk analysis procedures and resulted in the initiation of the flight without a comprehensive preflight weather evaluation, leading to the pilot’s inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain. Contributing to the accident was the Federal Aviation Administration’s inadequate oversight of the operator’s risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.
Even the FAA gets a slap. Remember the two Shuttles were br ought down by normalisation of deviance, so it's not confined to the low end of GA. It's very rare that an accident is the result of a single cause, like the pilot not standing up to organisational pressure, the NTSB has told us why the pilot in this case possibly didn't - punitive repercussions.
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Old 21st May 2020, 05:35
  #112 (permalink)  
 
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The management of Survival Flight should be in court and, very shortly afterwards, in jail.
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Old 21st May 2020, 13:30
  #113 (permalink)  
 
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It seems that the culture of total disregard for policy and regulation in this HEMS organization was extreme. Does anyone believe this is the norm in the HEMS industry or is this just an example of a rogue operator?
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Old 21st May 2020, 19:31
  #114 (permalink)  
 
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Still operating.
https://www.survivalflightinc.com/about-us/
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Old 22nd May 2020, 01:56
  #115 (permalink)  
 
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is the norm in the HEMS industry or is this just an example of a rogue operator
It's a feature that exists all over the place, even in Fortune 500 companies. One company had its pilots on staff and they were subject to a yearly appraisal as to what, if any, yearly salary increase may be received, made sure things were done the company way, not what ops manual or regs said.
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Old 22nd May 2020, 21:22
  #116 (permalink)  
 
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The 407 is pretty much a Longranger with 4 blades and lots more power. Easy to slip into a turn if banking more than standard rate and not adding enough collective. Perilously easy if in IMC or pitch darkness and not tight on the instruments.

Last edited by Torquetalk; 22nd May 2020 at 21:34.
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Old 22nd May 2020, 21:32
  #117 (permalink)  
 
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Originally Posted by Two's in View Post
As much as the threat to a regular paycheck is always a major consideration, there are very few HEMS accidents that can't be root caused back to poor airmanship. Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable risk. If (as a Captain) you are unable to do that, commercial flying may not be for you.
True but culture and context are powerful. Otherwise we are still stuck at blaming pilots for making decisions which are wrong in hindsight. Yet they are rewarded and good pilots who get on when it doesn’t go wrong... Insidious and implicitly dangerous.

Reminds me of the old joke about the aborted take-off due to unusual engine noise. Took the company an hour to find a replacement crew that wasn’t bothered by the noise.

Last edited by Torquetalk; 22nd May 2020 at 21:58.
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Old 8th Jun 2020, 20:05
  #118 (permalink)  
 
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NTSB Final Accident Repost issued: https://www.ntsb.gov/investigations/...ts/AAR2001.pdf
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Old 13th Jun 2020, 03:03
  #119 (permalink)  
 
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I i ever

Originally Posted by Airbubba View Post
If I walked in to work and the aircraft was already running..To the pilot on duty, "go out and shut that damn thing off". One of us might be leaving the company permanently depending on what happens next. So many things wrong with this entire situation but that one really struck me as outrageous. I can assure you that at the EMS program where I work, a running aircraft awaiting my arrival and immediate departure would NEVER happen.
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Old 13th Jun 2020, 05:57
  #120 (permalink)  
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Originally Posted by grumpytroll View Post
If I walked in to work and the aircraft was already running..To the pilot on duty, "go out and shut that damn thing off". One of us might be leaving the company permanently depending on what happens next. So many things wrong with this entire situation but that one really struck me as outrageous. I can assure you that at the EMS program where I work, a running aircraft awaiting my arrival and immediate departure would NEVER happen.
and there in is the actual cause of the accident.
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