Posted 8 years 259 days ago ago by jhadmin
By Ed MacDonald - It was a morning like no other. Key members of the management team sat around the conference table with bleary red eyes and a demeanor which reflected their shared loss and pain from the night before. Self-doubt and a sense of their own human frailty permeated each team member down to the core. What could have prevented this tragic event? Why didn’t they see it coming? This gray cool drizzly morning would be the beginning volley in a long and eventually fruitful period of introspection and soul searching for the management team. The pain on the faces of the team members was palatable but would eventually lead to a stronger and safer organization---the hard way. It begged the question of “what signs did we miss”? Was this a case of misdirected management, poor training, carelessness, equipment, culture, or just blind fate? The NTSB would be arriving mid-afternoon and would begin the tedious process of putting the chain of broken pieces together. The painful calls had been made to next-of-kin and team members. There wasn’t a dry eye in the house and a huge piece of them was now missing. No one at the table wanted to make those calls ever again. No one in the room would ever look at the air ambulance business and operations in the same light. Flight crew members and family were gathering in the ready room trying their best to console each other. The press corps was trying their best to corner anyone who knew anything about the event. The Communications Center was closing the book on the last elements of the Post Accident Plan. Communications specialists were introspectively trying to figure out “why”. Let’s flash back to days or weeks prior to this tragic and preventable event and look at each discipline a little more closely:
The program director and business managers had been very concerned that flight volumes were way down and felt somehow that the crews were contributing through poor or apathetic interaction with a few hospitals and the pilots should be a bit more aggressive taking flights that the nearby competitor was grabbing from them. She had been to some of the safety courses at the Air Medical conferences but really felt as though those lessons learned were for other programs not hers. After all, they had gone fifteen years without an accident and had even been highlighted on the local television news station for their stellar safety record. They were going to get around to implementing a safety management system soon enough but marketing and financial issues seemed more pressing with the shrinking flight volume. Since they had no formal incident reporting systems there was not really any way to spot trends except for word of mouth. She was very comfortable with their safety record and felt that the past accolades somehow protected them from future problems. She tried to avoid pressuring the pilots or medical crews directly but the few subtle and worried comments about declining flight numbers in the hall and a few “pep talks” at team meetings should be having some affect on the teams by now. She did, however, remember watching a few pilots get fired because they just weren’t “team” players or didn’t get along well with a few flight nurses along the way. One particular pilot was just too slow and conscientious and never launched quickly enough for them. Most pilots pushed hard and were pretty rushed to get their twin engine helicopter off the ground in the six minute window. If they didn’t--they had to fill out a tedious deviation form and chat with the lead pilot. The lead pilot had been counseled on several occasions by the operator’s business managers about how important the upcoming contract renewal was and that pleasing the program management was so very important. The business model and the bottom line were driving most of the decisions.
John arrived just barely on time for shift change the night before. The shift change briefing was so hurried that he actually didn’t remember whether or not the outgoing pilot had said something about an electrical smell or not. His piloting skills were legendary, at least in his own mind, and surely among his circle of drinking buddies. He always felt that “Truly superior pilots are those who use their superior judgment to avoid those situations where they might have to use their superior skills.” He had managed to get himself into some very tight situations in the past and always extricated himself from a potential embarrassing moment or worse. He was feeling a bit irritable and tired but had been there and done that many a time before. He had attempted to get a nap that afternoon but the kids were pretty noisy and he was sure that sleep was what he caught up with on the night shift. He grabbed a candy bar and an energy drink as he left the house as his evening meal. Just prior to leaving the house he had a heated argument with his wife about their spending habits that were mimicking those of the federal government. The hefty new boat payment and the lack of workover opportunities were causing the family budget to go deeper into debt. He had picked up an opportunity to fly some part-time shifts with the local television station and was doing a little flight instruction to supplement their income but it just wasn’t enough. It didn’t help matters that there were increasing rumors of more company base closings circulating and flight volumes had been way down since another competing helicopter had been recently placed at a nearby airport within two miles of them. The state didn’t really have any oversight controlling EMS helicopters so that air ambulance market was just saturated. Most everyone in the field knew that there just wasn’t enough business for both of them. Competition hadn’t been based on safety or quality of service but how many pizzas, gadgets and free gifts a service could provide the agencies and hospitals in the area. Some of area hospitals or EMS agencies would continue to shop around until they could find a helicopter even after weather turn-downs by one operator.
John wasn’t concerned about his lack of sleep or nasty mood because they rarely flew at night in the last few months as the other competitor’s helicopter was pulling in those flights because they were a fully instrumented program with night vision goggles. John’s operator had their base on the company list for goggles but it was still several months down the road before they would see them. They still did things the “old fashioned way” and he had misgivings about the new fangled technology anyway. He slowly walked out the helicopter and casually walked around to insure that the big pieces were still there. He thought to himself that he really should do a more thorough preflight but had left his flashlight in crew quarters. Besides, he had thoroughly checked the aircraft five days ago at hitch change and it really had flown only once since then. He only did a really thorough by-the-book pre-flight if either the FAA or Check Airman was watching. It felt a little sloppy to him but he had other things on his mind this evening. He had been counseled a few times by the Lead Pilot for missing a few key items on his preflight that led to a cowling flying off at a hover and a shore power cord dropping off at two hundred feet but he felt his long tenure at the program and popularity made him essentially invulnerable, ten feet tall and bullet-proof.
The medical crew consisted of a veteran flight nurse and a gung-ho yet brand new flight paramedic. Jan had been a flight nurse for over ten years now and nothing much fazed her. She had seen pilots come and go at the program but was good friends with John, tonight’s pilot. They had been through some trying times and a few close calls together but now she was very comfortable with John and never questioned his decisions. They had plans to meet next week for a family picnic at the State fair next weekend. Our evening’s paramedic, Chad, was a veteran fire fighter paramedic and prior Army Special Forces medic with some experience in the Gulf War years ago. He was the poster child for physical fitness and bravado. His paramedic skills were legend at the county fire department and this was his first shift after completing the very short indoctrination hurriedly completed by the program last week. Most of the training was oriented toward the equipment and clinical protocols. His crew resource management (or Air Medical Resource Management (AMRM)) training was postponed until the annual training cycle met in six months. He had some reservations about his readiness but knew that he was with an experienced crew and would just follow their lead. Jan had gone through so many AMRM classes she could recite the redundant points in her sleep.
The Communications Specialist was crammed into a small room that could well have doubled as a closet. They had most of the radios and phones required to get an aircraft off the ground but flight following was weak due to a lack of repeaters and alternate methods to track an aircraft in flight. It was cramped and stuffy and a hard place to sit in for hours. There really wasn’t enough business at night to warrant a relief specialist at night so if he needed a break the phones and radios simply went un-manned. Bill was on duty for his tenth straight night shift and had come in six hours early due to a sick call. He had been at the program for about five years and felt it was certainly a more comfortable way to make a living than riding a truck on those foggy cold nights as a medic. He had heard far too many rumors that the program was in financial jeopardy and was going to make sure he captured every flight possible. The operator’s operational control was just a paperwork drill for the FAA but really ineffective in overseeing pilot decision-making.
The Final minutes:
The call from the rural fire department dispatch came in at 03:25 to Bill for a multi-car accident with serious life threatening injuries. That dispatch said that the other nearby program was enroute and they urgently needed help. Bill diligently copied the information and rousted the pilot from what was apparently a very deep sleep. John heard the tones go off but couldn’t find the radio to respond. He was groggy and somewhat disoriented but the cobwebs slowly dissipated as he rolled out of bed. John didn’t remember if he had checked the weather before falling into bed nor whether he had updated their weather status. Earlier in the evening he had seen some halos around the street lights and felt a little more moisture than usual in the air but never really checked the temperature and dew points in the region. When he finally put together the dispatch information together in his head and heard the urgency in Bill’s voice he began to move a little quicker. He meant to check the computer based weather in that very dark and hilly part of the county but as he walked to the helicopter he saw stars through the pitch black night and decided it would be just fine. Communications hadn’t mentioned any weather issues nor relayed that the competitor had turned around five minutes into their flight since no one told him. John hurriedly climbed into the cockpit. He cursed at himself that his flashlight was still sitting on the bedside table but knew it was only a fifteen minute leg to the scene. As he strapped in the crew arrived at the helicopter and were climbing aboard as he pulled the trigger to get going. He thought to himself that perhaps someone should have walked around but they were in too big a hurry this time. They all knew that a quick launch looked good to management and this was an urgent call requiring their services right away. They were a crew whose dedication to the profession of saving lives was admirable. They really cared about this avocation of service and would go to any lengths to help others.
The new paramedic had mumbled something to the flight nurse as they rode up the elevator to the helipad. It was some vague remark from his county medic buddy earlier that evening reporting heavy fog on the hilltops. She was too busy going over rapid sequence intubation procedures in her head and the weather comment went unattended. Besides, she had seen the bright stars over the helipad as they walked to the helicopter as well. She knew that her experienced pilot for the evening wouldn’t push if the weather got gnarly especially after the close call they had last shift.
John gave his takeoff information to the communications center and yanked the aircraft into the night. The flight over the city lights was clear and smooth. As they reached the end of the city glow below them he tried desperately to see into the pitch black terrain in front of them. A few wispy clouds passed around them but the mushy darkness ahead warned ominously or perils ahead. John was busy trying to identify the intermittent flash of a panel caution light that distracted him from the route ahead. He had flown this route many times before. His altitude was good enough for the next mile or so but he dared not climb too high as the wispy clouds might indicate a ceiling closer than expected. He still could not see any lights ahead nor any horizon. His attempt to contact the communications center went unanswered. He anxiously told the crew that they should see the next town lights very soon as the GPS indicated it was only two miles ahead of them. He was considering turning around but thought he should see lights and horizon any time now. The crew was acting a bit nervous but said nothing. They knew that John had plenty of experience and would never push. John was getting very nervous now and pondering climbing into the clouds for an instrument recovery. His last instrument work was well over eight months ago and he had little confidence in those skills. The team never spoke up nor knew what they hit that dark night. It was over in a micro-second. This time they were about a minute too late to turn around.
Authors Note: This article is basically an updated version I wrote for the Air Medical Journal titled “The Next Accident” in 2001. It does not reflect any particular persons, companies, or situations. None of the people in the story are real but it very well could have been any of us…or could yet be.