chopper 2004, that's a pretty chilling video to watch. I commend the pilot for being open and upfront about the whole episode. One thing that struck me was his reference to an apparent unreliable attitude indicator and his decision to cage the instrument in flight.

It reminded me of this excellent article by Elan Head in Vertical Magazine about another highly experienced pilot who, after an inadvertent entry into IMC, experiences a mismatch between his vestibular senses and his attitude indicator an proceeds to disable his one and only lifeline.

After eighteen years of flying I have several thousand hours of IFR time; several hundred hours of actual IMC time and probably at least fifty hours of hand flying in IMC. Even so I would estimate my ability to fly an AS350 in IMC conditions at a few minutes tops. Back when I actually did fly EMS in an AS350 I probably would not have lasted for more than a few seconds in IMC.

The thing is, I was instrument rated and -in theory- fully qualified to fly in IMC conditions. Why do I think I would I have only lasted for a few seconds? Because I had zero actual IMC experience and because I had no stability augmentation; no EGPWS or TAWS, no weather radar and only a tiny ADI to look at. Faced with inadvertent IMC I would have likely reached over and caged the ADI too, unable to process the overload of conflicting sights and sensations.

This is, by and large, the current state of the EMS industry: otherwise competent pilots who are not qualified to fly in IMC conditions are being sent out in aircraft that are not properly instrument equipped. It should not be a surprise that this leads to incidents and accidents.

Autopilot needed
 

Having flown EMS for seven years in an AS350, Bell 407, BO and BK, I believe that properly used, an autopilot would have saved many lives over the years. If Insurance companies were of the same mind, I believe that a discount offered for every helicopter sporting an autopilot would encourage operators to install them.

So he caged the AI in flight, stated he didn't look at it again and made a series of random control inputs to rectify his situation without actually looking at the altimeter or AI!

Yes, there were unacceptable ops pressures and the questioning of his decision not to go but he failed on every count to take appropriate IIMC actions. He and his crew were incredibly lucky not to crash.

I think Gomer Pylot's comments about total hours and continuity of flying experience are very germane to this incident.

What was he doing staring at a bright light anyway - no better way of screwing your night vision!

Was the AI problem because he had shut down and not completed the startup checks properly?

A proper set of instrument checks (especially if you think there is a real risk of IIMC) would have been the professional thing to do.

A lot of self-induced pressure here.

I think that small investment in second pilot for night operations (NOT in second engine, one is just enough) would significantly improve the safety record. As it is in Europe. IMHO.

JR

And where would you put this second pilot? In most light helicopters used in HEMS in the US, the patient occupies the left seat. At least the patient's legs, with the rest of him/her in the back seat with the med crew. And the helicopter is departing at or near max gross weight now, and with a copilot on board the patient would have to be a child, no bigger. Replacing that many helicopters with larger models would take years, because they just don't exist now. Helicopters don't just magically appear, they have to be built on a production line, and that takes a long time.

Yes GM, I agree with you. Mission impossible. And again, money talks.

Second pilot?
 

I believe that in an inadvertent IMC situation, a second pilot may only confuse the first pilot and vice versa. At best, maybe encourage the PIC to abort the mission sooner. I would rather have a non-vertigo prone autopilot. One whose default position is wings straight and level. One that is easily overridden in order to climb, communicate and confess. One that will resume straight and level if the pilot gets confused. Most pilots that lose it in IMC do fine in their bi-annual instrument check ride. It's the emotional fear element that trips up the pilot in a life-threatening unfamiliar environment. It's called sensory overload. An autopilot is like that check airman when you are under the hood. You almost never need them, but it's calming to know that they're there.

Yes, it's possible solution...but IIMC is not the main cause of HEMS accidents (at least not in the last two accidents).
As far as I know, in Europe, EASA 965/2012 regulative, PART-OPS, second pilot in night HEMS operations is mandatory. Does that make sense?

JR

An outsider to HEMS and cognizant of the excellent though disturbing video link, but if I were the FAA I think I would mandate within a short period of time, in line with the SMS requirements now demanded from operators, that every member of management, aircrew and operational groundstaff attend a CRM course together with customer management, medical teams discussing past major accidents and their causes with a view to an eventual overhaul of the operator's Safety Case with revision of SOP's as necessary plus encouragement of an individual mission risk assessment performed by operational staff taking into account aircraft limitations, crew training, weather and facilities. Mitigations as the risk increases including saying no should be clearly laid out. Bull**** I hear some cry ..... but nothing else seems to have had sufficient effect - this should be seen as the perfect opportunity to encourage frank discussions and understanding / acceptance, by management from both operator and customer, of the limitations of machine and human which in the end might reduce pressure to get on and complete missions regardless. Even better do this with several operators together if practical, and repeat as necessary. Surely this is a duty of care for the patient?

Fly911 - I completely agree. A decent autopilot offloads the pilot to allow him the extra capacity to make decisions.

Single pilot IFR is difficult enough when you plan it - when it is suddenly forced upon you it can be overwhelming.

A decent autopilot will have a go-around button which will put wings level and capture a sensible climbing speed. If the pilot in this incident had had such a facility (and known how to use it), we wouldn't be reading about it.

Tistisnot - the CRM is a good idea but financial/operational pressures have a way of making people ignore the sort of lessons that are learned on those courses.

CRAB
 

It's easy to forget that a prime cause of disorientation (from our sim training experience) is inadvertent deselection of the AP's because some wizard of a designer put two buttons on the cyclic that pilots confuse regularly, one de-couples the FD and the other (curiously labelled "SAS REL") will simultaneously remove both AP's. The subsequent melee is very exciting IMC and no amount of GA button pushing will help you. If only they had organised the 'AP Release' (my chosen new title for that button) so that one push takes out just one AP and a second push remove the other AP then guys would not get themselves into that situation.

So the message is that you should develop a good recovery strategy for unusual attitudes and practice it regularly in the sim. Forget the GA button, despite the statements in the RFM it may actually add to your problems rather than solve them.

Note - this may not apply to all types but check out your own systems before signing up to the "The GA button will save my life" club.

G.

Geoffers,

I agree that designers often don't understand much about how an aircraft is piloted and that the positioning of important buttons is often rather random.

However, If the pilot is averagely aware of his autopilot functions and uses them regularly then something like the GA button can be a lifesaver - it doesn't beat a decent instrument scan and regular IMC exposure though.

Our GA button is on the collective (even though it works through the cyclic channel) and, providing the AP hasn't been inadvertently selected off, works surprising well as a recovery from UPs.

CRAB
 

Yes but.....

When disorientation bites you may have very little time to gather things up and restore order, ask yourself if you are going to send your thought processes around the 'what is causing this?' circle before adopting a recovery strategy. My suggestion is that you may be better off just sorting the thing out with not even a nano second of delay. I'm not sure about other types but certainly the 139 has a great deal of control power and if the AP misbehaves or drops out the response levels are so high that you can be upside down in two or three seconds. It's been done for real so no hyperbole here.

G.

Geoffers - yes, immediate UP recovery is most definitely the answer which is why it is practised AP out on every military type I have flown - is that the same for the guys that you get coming through?

Unusual Attitude Recovery Training
 

We are currently facing a dilemma insofar as AP out training is not allowed in the aircraft because the certification requires one AP to be serviceable at all times. Luckily we can continue to train AP's out in the sim because we are not covered by the same certification and not exposed to any danger.

Unfortunately the 139 sim, with both AP's out, is not a good training vehicle because it's response is not as good as the real aircraft and is far to difficult for most TR students to manage. We stick with a sample of scenarios that may use SAS only or AP's 'IN' and extreme attitudes. In the training environment there is pay-back for building confidence rather than destroying it. We can save the more demanding stuff for the recurrent sessions where they are appropriate.

G.

So if they do go IIMC or inadvertantly deselect the AP out when IMC, they are probably going to scare themselves or even crash because they haven't been allowed to train for that situation - that is rather worrying.

Geoff/Crab: While interesting, I'm not sure that is relevant to the average low spec US HEMS helicopter with minimal flight simulation available either.

No, but what is relevant is whether or not those HEMS pilots ever get to practice UP recovery on instruments, with or without the AP.

Like so many advanced flying skills, Instrument Flying is a very perishable one.

US Specs
 

Not all helicopter operations in the US are 'low spec', at least in the case of larger operators. AMC operates 100+ 135/145's alone, in addition to other twins. That is certainly more than some countries entire EMS fleet combined. Simulator training is in place on the EC135, and recognizing the benefit of simulator training they had introduced a full motion simulator for singles (unfortunately the OEM was poor). AMC has also purchased 4 full motion Level 'D' simulators for singles and twins to be introduced shortly, with annual training in the sim for all pilots. 3 static 160º view procedural training devices have been in place for a long while further supplementing training on a biannual basis.

It's not all 'low spec' or devoid of training.

https://www.faa.gov/news/press_relea...m?newsId=18634

Press Release – FAA Proposes $1.54 Million Civil Penalty Against Air Methods Corp.
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For Immediate Release
April 13, 2015
Contact: Allen Kenitzer
Phone: 425-227-2015; Email: [email protected]
SEATTLE – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) proposes a $1.54 million civil penalty against Air Methods Corp. of Englewood, Colo., for allegedly operating Eurocopter EC-130 helicopters on dozens of flights when they were not in compliance with Federal Aviation Regulations.
The FAA alleges Air Methods operated two helicopters on 70 passenger-carrying flights for compensation or hire, over water and beyond power-off gliding distance from shore, when they lacked required helicopter flotation devices and flotation gear for each occupant. The agency alleges the company operated another helicopter on 13 such flights when it lacked required flotation gear for each occupant. All 83 flights by the emergency medical transport company occurred around Pensacola, Fla.
“The flying public correctly expects that American operators will place safety above all else,” said U.S. Secretary of Transportation Anthony Foxx. “We will hold operators accountable when they fail to meet those expectations.”
“Operators must follow every regulation and take every precaution to ensure the safety of all those on board,” said FAA Administrator Michael Huerta. “Flying without required safety equipment is indefensible.”
Air Methods has 30 days from the receipt of the FAA’s civil penalty letter to respond to the Agency.