EMS Aircraft Mishaps Increasing
Clark
Twenty-three years of accident-free medical rescues by UW Med Flight
ended in tragedy Saturday, with the fatal nighttime crash of an
American Eurocopter EC 135 helicopter on a wooded bluff five miles
outside downtown La Crosse on a return trip to Madison after ferrying
a patient to a La Crosse hospital. The craft lost contact with the
airport shortly after take-off at 10:48 p.m. Killed in the crash were
Dr. Darren Bean, nurse Mark Coyne and pilot Steve Lipperer.
The cause of the accident is under investigation by the National
Transportation Safety Board, but several studies have found
circumstances of such a flight -- at night and without a patient on
board -- are linked with high accident rates in what authorities have
identified as an alarming increase in the number of emergency medical
services aircraft crashes.
In 2006, the NTSB threatened to tighten regulation of air ambulances,
but opted instead for voluntary guidelines. The NTSB had launched a
special investigation into EMS operations and accidents after 55 air
ambulances, helicopters and fixed-wing craft crashed between 2002 and
2005 -- a level not seen for 20 years, authorities said. Recurring
safety issues identified in the study included: less stringent
requirements of EMS flights without patients on board; a lack of
flight risk evaluation programs for EMS operations; and no
requirements to use terrain awareness or night-vision technologies to
enhance safety.
Other studies have pointed to factors that increase air ambulance
crash rates. A 2006 Johns Hopkins University study of NTSB data on EMS
helicopter crashes between 1983 and 2005 found that the odds of a
fatal outcome were increased by a post-crash fire, bad weather and
darkness. Post-crash fires resulted in fatalities in 76 percent of
crashes, compared to 29 percent without fires. Weather conditions
requiring instrument navigation resulted in fatalities in 77 percent
of crashes, compared with 31 percent when pilots navigated visually.
Fifty-six percent of crashes occurring in darkness were fatal,
compared with 24 percent of crashes not in darkness.
There were no reports of a post-crash fire in Saturday's Med Flight
crash, and the conditions were not considered risky at take-off, UW
Hospital officials said.
The Air Medical Physician Association reported in 2002 that a study of
20 years of data showed that while 38 percent of all EMS helicopter
flights occur at night, 49 percent of accidents occurred at night. One
study cited by the AMPA identified peak accidents times, including
10-11 p.m. The AMPA report also found that 60 percent of air ambulance
crashes occur without a patient on board. Med Flight operated a fleet
of two EC 135s leased from Air Methods of Denver. The craft that went
down was secured in August. The Med Flight program averaged three to
four flights a day, transporting patients an average of 55 miles,
officials said. The program served a 225-mile radius. The state's
first EMS helicopter crash occurred in April 2006 when a craft
operated by Eagle III crashed at a Green Bay emergency service
heliport following a post-maintenance flight. The pilot was killed."
http://www.madison.com/tct/news/285826
I just went to a Helicopter Safety Forum in DFW sponsored by Flight
Safety. One thing that was discussed was application of CRM and SMS to
the helicopter communities, whether GOM, EMS, or Law Enforcement.
Companies will need to invest in these programs to reduce mishaps, and
it will be a challenge as the number of operations increase. Flight
Safety would be a good place to start.
http://www.flightsafety.com/
Pass this message along to any helo friends you know.
Fly Smart
Kent
Huey Pilot by trade
Carlos
One problem is that we don't have a program like the Federal Government has
that protects employees (Whistleblowers). If we say anything we get fired. I
wish there were more FAA Inspectors but that isn't going to happen either.
I've been working EMS here in Texas for around 15 months and I've only had 1
visit from the FAA and it wasn't even from the FSDO that my POI is from.
Carlos
--------------------------------------------------
From: "Clark" <lewis...@gmail.com>
Sent: Monday, May 12, 2008 2:59 PM
To: "Ft Worth Aviation Safety Program" <ftw...@googlegroups.com>
Subject: {ftwasp} EMS Aircraft Mishaps Increasing
Clark
Sounds as if there is a culture issue.
The FAA will be recommending Safety Management Systems to Part 135
operators soon, which requires an open, non-jeopardy reporting system.
When a company has a good safety culture they seek information from
their employees in a collaborative effort to improve not only safety
but their bottom line as well.
The 4 Pillars of SMS are Policy, Risk Management, Assurance and
Promotion. Good operators will be rewarded by lower loss rates and
discounts from insurance companies. Bad ones can look forward to
increased rates and oversight from Regulators. Advisory Circular
120-92 is for Air Carriers, the program will be similar for Part 135.
One issue that needs to be looked at is protections for reporters
similar to those provided by NASA ASRS. Right now one can keep their
FAA certificates but still lose their jobs. That is not a good safety
culture. The other factor you mentioned is the woeful understaffing of
FSDOs. I read recently that the FAA is hiring 850 Inspectors this year
but have not been able to confirm that.
Might I sugget that you establish a relationship with your FSDO
FAASTeam Program Manager by volunteering to be a member of the FAA
Safety Team. You can be a leader in SMS implementation at either your
current employer, or your NEW employer. Not trying to be trite, but if
the "Team" is not willing to improve, I'd look for another Team.
You can contact me off line if you wish and I will see if there is
anything I can facilitate.
lewis...@gmail.com
(817) 692-1971
On May 12, 7:13 pm, "Carlos" <Pilot13...@hotmail.com> wrote:
> One problem is that we don't have a program like the Federal Government has
> that protects employees (Whistleblowers). If we say anything we get fired. I
> wish there were more FAA Inspectors but that isn't going to happen either.
> I've been working EMS here in Texas for around 15 months and I've only had 1
> visit from the FAA and it wasn't even from the FSDO that my POI is from.
>
> Carlos
>
> > Kent
Kemp, John
An effective SMS is very difficult to establish. Bottom line, it is a quality management system applied to the functional area of safety (accident prevention). The elements of the SMS are no different than a traditional safety program, but the way they are implemented and managed is vastly different. The biggest thing is getting upper and middle managers learning and exercising their roles within the safety system. Executive management MUST hold upper management accountable, upper must hold middle managers accountable and middle must hold supervisors accountable and supervisors hold line personnel etc. All must have ownership within the system and exercise their roles in hazard identification and risk management/mitigation along with participating via various communication schemes.
A robust reporting system that includes confidential concern reporting in very important along with event reporting. Trending of the concerns, event findings and audit findings is the basis for continued SMS improvement activities.
FOQA and ASAP are two voluntary safety programs that are offered to 121 operators and most recently to 135 operators, both give companies and more importantly individual employees protection from retribution from either the company or the FAA per a signed memorandum, it also offers protection afforded under FOIA.
An SMS is not hard, Getting managers onboard is difficult, all they see is doing more work that they consider fluff. Once you get a management system fully implemented and culture working for you instead of against, everyone will be asking how they did it before, because things run a lot smoother.
Safety is not the Safety Officers responsibility, Safety is a common task associated with every employee.
________________________________
From: ftw...@googlegroups.com on behalf of Clark
Sent: Mon 5/12/2008 6:58 PM
To: Ft Worth Aviation Safety Program
Kent B. Lewis
Kent Lewis
(817) 692-1971
www.signalcharlie.net
Carlos
shotgun blasts in my right ear and the helicopter shake rattled and rolled
(well, not rolled in the aerobatic sense). I got it under control and did
everything by the book (manual). The medic at my side "with his vast
experience as a PASSENGER" started screaming "put it on the ground in that
field". Of course it was night and we were about 800agl with only 1 engine
working so since we were still flying I figured that the field is right
there but at this altitude I can't see and don't know if there are wires or
anything else in my path to the ground. If I decided to try it and as I got
close I found the wires then I'm in an OEI (One Engine Inop) situation that
I might not be able to fly out of. It's also night so it's harder to see any
obstacles.
Then there's the other option :
Follow the Flight Manual that says that if you're still able to fly at OEI
then continue flight and land as soon as practicable. Let's see, the airport
is about 3 miles away and there's fire/rescue there in case the run on
landing doesn't go as planned or the situation gets worse and we lose the
other engine and I have to autorotate, etc.
Incredible how good training and experience kicks in when you need it. I
went through this whole thought process in seconds and thought the airport
route decision was a "no brainer" so I called the tower and told them I had
an emergency and was coming in on one engine. As I was coming in for landing
all I could hear was the same medic saying "keep the nose up, keep the nose
up !". Glad I have a daughter and have learned the art of "tuning out
unwanted noise" so I did the correct thing and DIDN'T raise the nose and
flew it to a run on landing. After I landed the medic told the mechanic
that the landing was so smooth that he didn't feel we had touched the ground
until he started seeing sparks coming from the skids ( Atta boy for me ! ).
Well the atta boy didn't last long because the same medic called his boss
and told him that he wasn't comfortable flying with me because I didn't put
the helo in the closest field and we could have lost the other engine on our
way to the airport.
Well, I guess it was a matter of time. The fact that I've been actively
voicing my concerns for the last few months about the lack of following
checklists before take off and other maintenance and safety concerns going
on in the company didn't help so now I guess I'll have to try to participate
in the SMS program of my NEXT employer. I also learned that if I end up
working for another company that is so focused on keeping the customer happy
no matter what so they don't lose the contract, and places them before
safety, that I'll leave before the next engine out or worse.
--------------------------------------------------
From: "Clark" <lewis...@gmail.com>
Sent: Monday, May 12, 2008 5:58 PM
To: "Ft Worth Aviation Safety Program" <ftw...@googlegroups.com>
Subject: {ftwasp} Re: EMS Aircraft Mishaps Increasing
>
Kent B. Lewis
Good job getting the aircraft down safely and using your judgment as PIC.