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The safety challenge
An Editorial Opinion
EDITORIAL BOARD
The Safety Challenge By Howard M. Collett
Dennis Brimhall University of California Medical Center San Francisco, CA
Burton Harris, M.D. International Society of Aeromedical Services Boston MA
Jane Miller, R.N. Care Flight Reno NV
John Sonneveld Aeromedical Consultant Tyabb, Victoria Australia
Frank Thomas, M.D. Life Flight, LDS Hospital Salt Lake City UT
Allen Yearick Abbott-Northwestern Hospital Minneapolis MN
SAFETY ADVISORY COMMITTEE Frank Hearney Freedom Helicopters Shelley ID
Robert I-. Lash, M.D. LifeStar Knoxville TN
Roy Morgan Air Methods, Inc. Englewood CO
Noel Preston Aviation Consulting, Inc. Manhasset NY
Russ Spray Rocky Mountain Helicopters Provo UT
In the wake of the space shuttle disaster last January, the media has been replete with accusations as to the material and human factors surrounding the tragedy. One national magazine typed N A S A as a "bureaucracy under seige." As a result, N A S A officials and supporters have started to lash back at the press and other critics, including some astronauts. But regardless of the ultimate and contributing causes of the space shuttle explosion, one thing is certain: an accident can happen to anyone. In aeromedical circles, as in the Space Shuttle tragedy, accidents happen to (or are caused by) the best pilots. Accidents happen to (or are caused by) the best programs. And accidents have no regard for even the most experienced flight crews performing routine missions. While N A S A made the event of the century by putting men on the moon, the agency is not without flaws. And our aeromedical service network -- the largest in the world, responsible for transporting more than 70,000 critically-ill or injured patients last year - is not without some need of improvement. It's time to provide our pilots, programs, and flight crews with standards that will limit the exposure of aeromedical helicopters in areas of proven high risk. The question then becomes, who is responsible for the setting of such standards? Perspective Before addressing this responsibility, perhaps it would be well to review the accident situation and opinions of industry leaders and observers. The following excerpts have been taken from more than 30 articles and editorials over the past three years from Hospital Aviation: August, 1982: " . . . some duty schedules and/or a lack of definite operational guidelines draw an otherwise prudent pilot into untenable situations . . . Some restrictions need to apply to prevent an unacceptable risk factor." September 1983: "Less than 15% of aircraft operators have a good, solid safety program. The rest are a detriment to the i n d u s t r y . . . At the top of the list for low accident rate companies is management's concern and involvement, and their commitment to safety." January 1984: "Weather and/or night flying have been factors in 80% of hospital-based helicopter accidents resulting in fatalities or i n j u r i e s . . . Night flights should be allowed only to approved helipads or a i r p o r t s . . . If night flying is
to be done outside the boundaries of a well lighted urban area, a two axis stabilization system (or better) should be r e q u i r e d . . . Each program should require a minimum of t h r e e - a n d in some cases f o u r - p i l o t s for each aeromedical helicopter." August 1984: " . . . is the pilot guilty for flying in darkness, marginal weather and unknown terrain, or is program management at fault for routinely condoning such missions all too frequently in the past? It is the responsibility of each program to take a hard and serious look at the aviation component of its aeromedical operation, and pass judgment [regarding] the risk factors it allows its pilots and medical teams to face." March 1985: "By the end of 1984, nearly one out of every two hospital-based helicopter programs had experienced a reportable accident. And one out of every five programs had an accident which resulted in injuries or fatalities." September 1985: "Not every flight is worth taking. If forecasted or reported weather is below minimums, know when to walk away [from the flight]. Launching on a flight to 'see for yourself' what the weather is really like only surrounds the abort decision with a higher pressure environment." September 1985: "Complacency is something we all hear about, but unfortunately few of us do anything about it. Remembering the '99 times' we have completed a flight under marginal conditions is literally placing your life on the table, and rolling the dice each time you continue an unsafe practice." December 1985: "The fact that nearly all of our EMS helicopters are operating at or near maximum gross weight conditions, are flying into and out of small, hastilyprepared landing zones, at time requiring steep approaches and maximum performance takeoffs, and under [various] environmental conditions, should cause alarm gongs to go off in the crew's collective heads!" In addition to the efforts of this magazine, the safety (or lack thereof) aspect of aeromedical helicopter programs has been discussed at the last three A S H B E A M S annual conferences. In his outgoing address to the membership at the 1982 A S H B E A M S Conference, Joe Tye, retiring A S H B E A M S President, stated, "There have been a number of serious incidents over the last couple of y e a r s . . , we need to consider establishment within our organization some sort of safety monitoring
HOSPITALAVIATION,MARCH1986 5
An Editorial Opinion... system". Little progress, however, was realized until three years later, in Reno. In December, 1985, at the sixth annual conference in Reno, a standing-room only crowd attended the two safety sessions. While worthwhile discussions were generated, there were still several program representatives that failed to grasp that there was (and is) a safety problem in the aeromedical industry. Perhaps that disbelief was put to rest as during the three weeks that followed, three more fatal accidents occurred in the ranks of aeromedical programs. The tempo of safety concern quickly escalated. Safety Congress Since the year-end A S H B E A M S Conference, the topic of aeromedical safety has been discussed by two separate sessions of the EMS Committee of the Helicopter Association International (HAl). In addition, it is one topic of the ongoing ASTM (American Standards for Testing and Materials) committee investigating EMS transport. But never has it been addressed in greater detail than it was at a special "Safety Congress" hosted by A S H B E A M S during March. If people are not yet aware of the problem, it hasn't been for lack of information. The goal of the Safety Congress, held in Dallas, was to develop standards that would help diminish the unacceptable accident record of the aeromedical industry. To the credit of this congress, numerous recommendations were formulated during the three-day session. But the entire package was held by A S H B E A M S for further analysis, and possible presentation at the annual meeting scheduled for the end of October in Washington, D.C. I n s u r a n c e concerNs
Perhaps the reason that standards have yet to be developed is that 1) few aeromedical programs are alike, and 2) a single "right" way to do things does not exist. But the critical nature of the situation will not walt for continued analysis. Accident facts have been apparent for more than three years[ Numerous committees and subcommittees and organizations have addressed the subject from within the industry. National press and network media have picked up on our problem. And the two leading insurance underwriters of aeromedical helicopters are closely scrutinizing the situation. The latter category finally gets close to home. Losses among insurers of aeromedical helicopters have been significantly greater than anticipated. In an effort to quickly curb future losses, underwriters are reportedly considering such things as (1) no night scene flights, (2) all night flights will require two pilots, (3) no operator (including hospitals) with a single HOSPITAL AVIATION, MARCH 1986
aeromedical helicopter will be insured, and (4) dramatic increases in insurance premiums. While the first two issues are still in the discussion stage, the latter two are at our doorstep. At least one operator of a single aeromedical helicopter program has been denied insurance, and many 1986 insurance renewals have seen premium increases of 60% or more. And that minimum figure equates to a $3,000 increase per month for a twin-engine helicopter! In search of responsibility Perhaps it's time to stop studying and talking about it and start doing something about it! And rather than pass the obligation of safety to one or more of our associations, perhaps individual programs should look inwardly for the solution. No longer can administrators say safety costs too much! Aside from the direct cost of an accident in terms of human lives and suffering, damaged equipment and loss of program credibility, we are now seeing direct costs which could have better been spent to provide, for example, pilot proficiency flights, stabilization systems, or even an extra pilot on the schedule. In discussing the matter with Hospital Aviation's Editorial Board and Safety Advisory Committee (all of whom are directly or indirectly involved with aeromedical programs), members of ASHBEAMS, NFNA, NEMSPA, and numerous hospital and helicopter operator personnel, Hospital Aviation would like to direct a few questions for consideration collectively by the hospital CEO, the aeromedical program director, and the aviation vendor of each program. 1) Should the aeromedical crew ask themselves prior to every launch, "is this a safe mission?" In our haste to function within the golden hour, are we overlooking precious minutes? It is one thing to have a five minute launch at noon under a clear, blue sky to a traffic accident ten miles away. But it is quite another to attempt the same liftoff time at three in the morning with low clouds and a steady rain to a patient 50 miles distant. Perhaps every program needs a written protocol that requires a discussion of the safety aspect of the mission. Such a discussion should not ask, "will we look bad to the referring agency if we don't get off the ground, quick?" or "will the patient die if we don't go? But each and every mission should center around the question, "is this a safe mission?" At some point, every aeromedical pilot and crew member makes a judgment call under pressure. The only way to take the heat off is to evaluate the mission in terms of safety as well as patient need. Would it be prudent if the on-duty crew
met, instead of in a turning helicopter, at the dispatch center to evaluate the safety and potential risk of each mission? Weather is not the only concern. Pilot alertness, mission fuel, weight and balance, aircraft preflight (including cargo and engine door security) and potential scene flight hazards are all worthy of concern. 2) What weather minimums should be established for night cross-country flights? If difficulty is encountered by such a question, allow me to suggest a starting point: require altitude minimums of at least 1,000 feet above the ground and 2 miles horizontal visibility for departure, destination and enroute portions of the flight. While it may be arguable that many of our highly-experienced aeromedical pilots can fly at 300 and 1 safely most of the time, the fact remains that pilots can't see clouds at night away from the city lights. What does an experienced pilot (and more importantly, an inexperienced pilot) do when he punches into an unforseen cloud bank at 150 mph and 300 feet? He has just placed himself in an environment that passenger-hauling airplanes do not fly without an autopilot and/or two pilots and then only when on an approved, IFR approach to an airport! And that approach was planned well in advance and guarantees terrain/obstruction clearances. Conversely, an aeromedical pilot is in a relatively unstable aircraft, with no second pilot and probably no autopilot, and he certainly is not on an instrument approach. Nor is he in an obstruction-free glide path environment. To top it all off, if he inadvertently flies into the clouds, such an event will happen suddenly, with no time for planning. You say it won't happen to you? Then consider the facts that, according to a recent industry-wide study, 63% of all aeromedical pilots have inadvertently entered the clouds on an EMS mission during the past year! And a number of them (might one of them be at your program?) have flown inadvertent IFR more than ten times! Regional circumstances may justify waivers of such altitude restrictions down to 500/1, based on pilot experience (including recent night and instrument flying experience), flat terrain, helicopter stabilization equipment, backup attitude gyro, radar altimeter, etc. But programs should not be lulled into accepting such waivers without a thorough review and written approval of either 1) the chief pilot of the helicopter company (who is not one of the aeromedical pilots), or 2) review by competent outside aviation authority. Another approach would be to write specific weather minimums and procedures into the company Flight Operations Manual. This manual must be approved not only by the Chief Pilot but also
An Editorial Opinion... the FAA. But any waiver authorized by such procedures might still receive the written blessings b y the Chief Pilot after a thorough investigation of the waiver circumstances. A further qualification of minimums (and these are minimums, not standards for everyday operation) would be that under no circumstances should any portion of a cross-country flight be continued at an altitude of less than 500 feet or visibility of less than 1 mile -- regardless of the skill of the pilot or the sophistication of the equipment. Lower ground clearances offer absolutely no room for disorientation, let alone a compound emergency. And in cases of ice in the clouds or mountainous terrain, such limits might be closer to 1,000/three and 2,000/five respectively. 3) Should each aeromedical helicopter pilot be required to possess a current instrument rating? Possession of an instrument rating should not imply that the pilot will intentionally fly his helicopter (most of which are not certificated for IFR) in instrument conditions. It does imply, however, that the pilot has had some training relative to spatial disorientation
and unusual flight attitudes, either or both which often result from an inadvertent entry into the clouds. It also implies that if a pilot punches into the clouds at 500 feet at night, he has the option and the skills to climb into the air instead of descend into the rocks. 4) Should each aeromedical pilot be required to receive standardization flight training every six months? Currently, the majority of aeromedical operations provide only the FAA-mandated annual check ride. Many such check rides, performed often by other company pilots, offer little more than a 30-minute cursory review once a year. With two standardization flights, one could coincide with the present requirement for the annual FAA checkride. The other annual ride could be provided by someone other than a company check airman, such as a manufacturer instructor pilot or an instructor from a recognized flight proficiency school. Each checkride session could include simulated emergency procedures, instrument approaches, basic instrument climbs, descents, and turns, and unusual attitude recovery. The additional expense involved in such training flights might be built into the cost of the contract
agreement with the hospital, just like continuing education costs built into critical care nursing employment contracts. 5) Should each aeromedical contract have a minimum of three full-time pilots and one full-time mechanic per helicopter? The nature of aeromedical flying demands no less than three pilots - if for no other reason than providing pilots with a humane work schedule. Further, is it reasonable to require that these pilots should not be assigned to any other types of flying activities (charter, offshore, etc.)? If a hospital cannot afford aviation personnel fully dedicated to their EMS helicopter, should it be in the aeromedical helicopter business? Adding an additional pilot (and perhaps there should be four per helicopter at busy programs) does not automatically improve safety. But it goes a long way toward improving the quality of work and personal life - both factors affecting performance and judgment. 6) Should the development of safety programs be the responsibility of individual aeromedical programs or national organizations?
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HOSPITALAVIATION,MARCH1986
An Editorial Opinion... Underlying the success of the aeromedical helicopter concept was the marriage of a health care institution expert at providing medical care with an experienced helicopter operator expert at providing aviation services. It is this contractual team, at the program level, that must deal with the problem. The hospital (or sponsor) should work with the vendor of aviation services in establishing standards (some of which are outlined above). If additional resources are needed, the local entity has several directions in which to turn. The HA1 has developed a comprehensive safety manual for helicopter operations, and has a full-time safety director. The organization also has in-place an EMS committee established primarily for safety evaluation. (That committee has in its membership representatives from all the aeromedical organizations and is chaired by the manager of the largest aeromedical helicopter vendor). Other resources include a half-dozen professional aviation consulting firms, several of which are familiar with aeromedical operations. They offer comprehensive and objective operational safety audits or reviews. NEMSPA, representing more than 120 aeromedical pilots from the majority of hospital-based helicopter programs, has already published a landing zone safety pamphlet. In addition, the organization has in draft form both a pre-post accident plan and aeromedical operating standardization guidelines. ASHBEAMS and NFNA have already developed several guidelines and crew performance standards, and can assist in the crossover areas involving flight crew participation and ground crew orientation and related needs.
7) Should hospitals require aircraft operators to present in detail their safety program when responding to an invitation to bid for an aeromedicai service? It has already been established that each sponsor of an aeromedical program (with the assistance of industry associations and experts as required) should take the lead in enforcing operational, equipment and training standards to be required in bid specifications or other contract negotiations. The universal adoption and enforcement of improved standardization requirements is the only vehicle that will lead operators in a competitive bidding environment to develop or maintain viable safety and accident prevention programs, which will in turn help reduce aeromedical accident probability.
Summary From 1972 through the end of 1985, 83 % of all fatal aeromedical helicopter HOSPITAL AVIATION,MARCH 1986
accidents were attributed to "pilot error." Visibility (or the lack thereof) was definitely a measured complication observed in the statistics. Darkness and/or adverse weather were adverse factors in 93 % of these accidents. But pilot error is often only the last, albeit final event in a chain of events where operational protocols or other accepted practices may have created the proverbial "accident waiting for a place to happen." Based on the observation that there is a high correlation between darkness and/or adverse weather and pilot error accidents, Hospital Aviation poses that pilot error accidents can and must be reduced by providing the pilot with improvements in environment, skills and/or equipment with which to operate. Such improvements must result from administrative decisions. Environmental improvements may include (1) improved pilot scheduling to reduce fatigue and shift rotation, with the addition of a fourth pilot per helicopter on an active program; and (2) the adherence to responsible night weather minimums. Also on the list would be factors affecting fatigue or judgment, such as eating, smoking and drinking habits the night prior to duty. Improved skills may include (1) the requirement for an instrument rating for each pilot, and (2) maintaining instrument currency - both aimed at proficiency in spatial orientation for low visibility missions. A third factor would be increasing the number of check rides from annually to semi-annually, with an increase in quality by placing more emphasis on emergency and instrument procedures. Improved equipment might include (1) flight control stability augmentation, ("wing-leveler" or "autopilot") systems - to reduce pilot workload/overload, and (2) the utilization of twin-engine helicopters. It should be emphasized, however, that additional equipment will not compensate for. a faulty decision process that puts the pilot in a marginal condition in the first place. Hospital Aviation is aware that it is difficult to develop a set of standards that will fit every situation and find unanimous support. We are cognizant that differences in pilot skills, aircraft capabilities, and program geography can and should modify the basic rules. But it has been our observation that many of the accidents have resulted (at least in part) from the hesitation of hospital administrators, program directors, operating companies, pilots and transport teams to realize that accidents have, and will continue to happen to them if positive steps are not taken to minimize the classic problems. Accidents occur most often because of a disregard for operational policy, or a total lack of operational policy. Few of the foregoing recommendations
come without cost. But is that cost different in principle than the costs associated with the recertification and/or training received by physicians and nurses in the medical community? Do we want to continue to fly with pilots who received their last standardization and instrument training 15 years ago in Viet Nam? We don't fly helicopters that miss a 600-hour inspection; why fly with pilots who are not given the opportunity for preventive maintenance on their emergency procedures? But aside from increased training, scheduling, and helicopter equipment, perhaps the most important safeguard involves a simple question. In the past, the emphasis has been on justification by a pilot or crew as to why a particular mission was turned down or cancelled. Shouldn't this approach be emphatically reversed? Shouldn't pilots be required instead to justify the acceptance of any mission if it increases the risk of the flight crew? Only when missions and their associated risks are appropriately managed in light of current technology and prudent judgment will the accident rate of the aeromedical industry be turned around. And that day won't come any too soon.
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EDITORIAL BOARD
The Safety Challenge By Howard M. Collett
Dennis Brimhall University of California Medical Center San Francisco, CA
Burton Harris, M.D. International Society of Aeromedical Services Boston MA
Jane Miller, R.N. Care Flight Reno NV
John Sonneveld Aeromedical Consultant Tyabb, Victoria Australia
Frank Thomas, M.D. Life Flight, LDS Hospital Salt Lake City UT
Allen Yearick Abbott-Northwestern Hospital Minneapolis MN
SAFETY ADVISORY COMMITTEE Frank Hearney Freedom Helicopters Shelley ID
Robert I-. Lash, M.D. LifeStar Knoxville TN
Roy Morgan Air Methods, Inc. Englewood CO
Noel Preston Aviation Consulting, Inc. Manhasset NY
Russ Spray Rocky Mountain Helicopters Provo UT
In the wake of the space shuttle disaster last January, the media has been replete with accusations as to the material and human factors surrounding the tragedy. One national magazine typed N A S A as a "bureaucracy under seige." As a result, N A S A officials and supporters have started to lash back at the press and other critics, including some astronauts. But regardless of the ultimate and contributing causes of the space shuttle explosion, one thing is certain: an accident can happen to anyone. In aeromedical circles, as in the Space Shuttle tragedy, accidents happen to (or are caused by) the best pilots. Accidents happen to (or are caused by) the best programs. And accidents have no regard for even the most experienced flight crews performing routine missions. While N A S A made the event of the century by putting men on the moon, the agency is not without flaws. And our aeromedical service network -- the largest in the world, responsible for transporting more than 70,000 critically-ill or injured patients last year - is not without some need of improvement. It's time to provide our pilots, programs, and flight crews with standards that will limit the exposure of aeromedical helicopters in areas of proven high risk. The question then becomes, who is responsible for the setting of such standards? Perspective Before addressing this responsibility, perhaps it would be well to review the accident situation and opinions of industry leaders and observers. The following excerpts have been taken from more than 30 articles and editorials over the past three years from Hospital Aviation: August, 1982: " . . . some duty schedules and/or a lack of definite operational guidelines draw an otherwise prudent pilot into untenable situations . . . Some restrictions need to apply to prevent an unacceptable risk factor." September 1983: "Less than 15% of aircraft operators have a good, solid safety program. The rest are a detriment to the i n d u s t r y . . . At the top of the list for low accident rate companies is management's concern and involvement, and their commitment to safety." January 1984: "Weather and/or night flying have been factors in 80% of hospital-based helicopter accidents resulting in fatalities or i n j u r i e s . . . Night flights should be allowed only to approved helipads or a i r p o r t s . . . If night flying is
to be done outside the boundaries of a well lighted urban area, a two axis stabilization system (or better) should be r e q u i r e d . . . Each program should require a minimum of t h r e e - a n d in some cases f o u r - p i l o t s for each aeromedical helicopter." August 1984: " . . . is the pilot guilty for flying in darkness, marginal weather and unknown terrain, or is program management at fault for routinely condoning such missions all too frequently in the past? It is the responsibility of each program to take a hard and serious look at the aviation component of its aeromedical operation, and pass judgment [regarding] the risk factors it allows its pilots and medical teams to face." March 1985: "By the end of 1984, nearly one out of every two hospital-based helicopter programs had experienced a reportable accident. And one out of every five programs had an accident which resulted in injuries or fatalities." September 1985: "Not every flight is worth taking. If forecasted or reported weather is below minimums, know when to walk away [from the flight]. Launching on a flight to 'see for yourself' what the weather is really like only surrounds the abort decision with a higher pressure environment." September 1985: "Complacency is something we all hear about, but unfortunately few of us do anything about it. Remembering the '99 times' we have completed a flight under marginal conditions is literally placing your life on the table, and rolling the dice each time you continue an unsafe practice." December 1985: "The fact that nearly all of our EMS helicopters are operating at or near maximum gross weight conditions, are flying into and out of small, hastilyprepared landing zones, at time requiring steep approaches and maximum performance takeoffs, and under [various] environmental conditions, should cause alarm gongs to go off in the crew's collective heads!" In addition to the efforts of this magazine, the safety (or lack thereof) aspect of aeromedical helicopter programs has been discussed at the last three A S H B E A M S annual conferences. In his outgoing address to the membership at the 1982 A S H B E A M S Conference, Joe Tye, retiring A S H B E A M S President, stated, "There have been a number of serious incidents over the last couple of y e a r s . . , we need to consider establishment within our organization some sort of safety monitoring
HOSPITALAVIATION,MARCH1986 5
An Editorial Opinion... system". Little progress, however, was realized until three years later, in Reno. In December, 1985, at the sixth annual conference in Reno, a standing-room only crowd attended the two safety sessions. While worthwhile discussions were generated, there were still several program representatives that failed to grasp that there was (and is) a safety problem in the aeromedical industry. Perhaps that disbelief was put to rest as during the three weeks that followed, three more fatal accidents occurred in the ranks of aeromedical programs. The tempo of safety concern quickly escalated. Safety Congress Since the year-end A S H B E A M S Conference, the topic of aeromedical safety has been discussed by two separate sessions of the EMS Committee of the Helicopter Association International (HAl). In addition, it is one topic of the ongoing ASTM (American Standards for Testing and Materials) committee investigating EMS transport. But never has it been addressed in greater detail than it was at a special "Safety Congress" hosted by A S H B E A M S during March. If people are not yet aware of the problem, it hasn't been for lack of information. The goal of the Safety Congress, held in Dallas, was to develop standards that would help diminish the unacceptable accident record of the aeromedical industry. To the credit of this congress, numerous recommendations were formulated during the three-day session. But the entire package was held by A S H B E A M S for further analysis, and possible presentation at the annual meeting scheduled for the end of October in Washington, D.C. I n s u r a n c e concerNs
Perhaps the reason that standards have yet to be developed is that 1) few aeromedical programs are alike, and 2) a single "right" way to do things does not exist. But the critical nature of the situation will not walt for continued analysis. Accident facts have been apparent for more than three years[ Numerous committees and subcommittees and organizations have addressed the subject from within the industry. National press and network media have picked up on our problem. And the two leading insurance underwriters of aeromedical helicopters are closely scrutinizing the situation. The latter category finally gets close to home. Losses among insurers of aeromedical helicopters have been significantly greater than anticipated. In an effort to quickly curb future losses, underwriters are reportedly considering such things as (1) no night scene flights, (2) all night flights will require two pilots, (3) no operator (including hospitals) with a single HOSPITAL AVIATION, MARCH 1986
aeromedical helicopter will be insured, and (4) dramatic increases in insurance premiums. While the first two issues are still in the discussion stage, the latter two are at our doorstep. At least one operator of a single aeromedical helicopter program has been denied insurance, and many 1986 insurance renewals have seen premium increases of 60% or more. And that minimum figure equates to a $3,000 increase per month for a twin-engine helicopter! In search of responsibility Perhaps it's time to stop studying and talking about it and start doing something about it! And rather than pass the obligation of safety to one or more of our associations, perhaps individual programs should look inwardly for the solution. No longer can administrators say safety costs too much! Aside from the direct cost of an accident in terms of human lives and suffering, damaged equipment and loss of program credibility, we are now seeing direct costs which could have better been spent to provide, for example, pilot proficiency flights, stabilization systems, or even an extra pilot on the schedule. In discussing the matter with Hospital Aviation's Editorial Board and Safety Advisory Committee (all of whom are directly or indirectly involved with aeromedical programs), members of ASHBEAMS, NFNA, NEMSPA, and numerous hospital and helicopter operator personnel, Hospital Aviation would like to direct a few questions for consideration collectively by the hospital CEO, the aeromedical program director, and the aviation vendor of each program. 1) Should the aeromedical crew ask themselves prior to every launch, "is this a safe mission?" In our haste to function within the golden hour, are we overlooking precious minutes? It is one thing to have a five minute launch at noon under a clear, blue sky to a traffic accident ten miles away. But it is quite another to attempt the same liftoff time at three in the morning with low clouds and a steady rain to a patient 50 miles distant. Perhaps every program needs a written protocol that requires a discussion of the safety aspect of the mission. Such a discussion should not ask, "will we look bad to the referring agency if we don't get off the ground, quick?" or "will the patient die if we don't go? But each and every mission should center around the question, "is this a safe mission?" At some point, every aeromedical pilot and crew member makes a judgment call under pressure. The only way to take the heat off is to evaluate the mission in terms of safety as well as patient need. Would it be prudent if the on-duty crew
met, instead of in a turning helicopter, at the dispatch center to evaluate the safety and potential risk of each mission? Weather is not the only concern. Pilot alertness, mission fuel, weight and balance, aircraft preflight (including cargo and engine door security) and potential scene flight hazards are all worthy of concern. 2) What weather minimums should be established for night cross-country flights? If difficulty is encountered by such a question, allow me to suggest a starting point: require altitude minimums of at least 1,000 feet above the ground and 2 miles horizontal visibility for departure, destination and enroute portions of the flight. While it may be arguable that many of our highly-experienced aeromedical pilots can fly at 300 and 1 safely most of the time, the fact remains that pilots can't see clouds at night away from the city lights. What does an experienced pilot (and more importantly, an inexperienced pilot) do when he punches into an unforseen cloud bank at 150 mph and 300 feet? He has just placed himself in an environment that passenger-hauling airplanes do not fly without an autopilot and/or two pilots and then only when on an approved, IFR approach to an airport! And that approach was planned well in advance and guarantees terrain/obstruction clearances. Conversely, an aeromedical pilot is in a relatively unstable aircraft, with no second pilot and probably no autopilot, and he certainly is not on an instrument approach. Nor is he in an obstruction-free glide path environment. To top it all off, if he inadvertently flies into the clouds, such an event will happen suddenly, with no time for planning. You say it won't happen to you? Then consider the facts that, according to a recent industry-wide study, 63% of all aeromedical pilots have inadvertently entered the clouds on an EMS mission during the past year! And a number of them (might one of them be at your program?) have flown inadvertent IFR more than ten times! Regional circumstances may justify waivers of such altitude restrictions down to 500/1, based on pilot experience (including recent night and instrument flying experience), flat terrain, helicopter stabilization equipment, backup attitude gyro, radar altimeter, etc. But programs should not be lulled into accepting such waivers without a thorough review and written approval of either 1) the chief pilot of the helicopter company (who is not one of the aeromedical pilots), or 2) review by competent outside aviation authority. Another approach would be to write specific weather minimums and procedures into the company Flight Operations Manual. This manual must be approved not only by the Chief Pilot but also
An Editorial Opinion... the FAA. But any waiver authorized by such procedures might still receive the written blessings b y the Chief Pilot after a thorough investigation of the waiver circumstances. A further qualification of minimums (and these are minimums, not standards for everyday operation) would be that under no circumstances should any portion of a cross-country flight be continued at an altitude of less than 500 feet or visibility of less than 1 mile -- regardless of the skill of the pilot or the sophistication of the equipment. Lower ground clearances offer absolutely no room for disorientation, let alone a compound emergency. And in cases of ice in the clouds or mountainous terrain, such limits might be closer to 1,000/three and 2,000/five respectively. 3) Should each aeromedical helicopter pilot be required to possess a current instrument rating? Possession of an instrument rating should not imply that the pilot will intentionally fly his helicopter (most of which are not certificated for IFR) in instrument conditions. It does imply, however, that the pilot has had some training relative to spatial disorientation
and unusual flight attitudes, either or both which often result from an inadvertent entry into the clouds. It also implies that if a pilot punches into the clouds at 500 feet at night, he has the option and the skills to climb into the air instead of descend into the rocks. 4) Should each aeromedical pilot be required to receive standardization flight training every six months? Currently, the majority of aeromedical operations provide only the FAA-mandated annual check ride. Many such check rides, performed often by other company pilots, offer little more than a 30-minute cursory review once a year. With two standardization flights, one could coincide with the present requirement for the annual FAA checkride. The other annual ride could be provided by someone other than a company check airman, such as a manufacturer instructor pilot or an instructor from a recognized flight proficiency school. Each checkride session could include simulated emergency procedures, instrument approaches, basic instrument climbs, descents, and turns, and unusual attitude recovery. The additional expense involved in such training flights might be built into the cost of the contract
agreement with the hospital, just like continuing education costs built into critical care nursing employment contracts. 5) Should each aeromedical contract have a minimum of three full-time pilots and one full-time mechanic per helicopter? The nature of aeromedical flying demands no less than three pilots - if for no other reason than providing pilots with a humane work schedule. Further, is it reasonable to require that these pilots should not be assigned to any other types of flying activities (charter, offshore, etc.)? If a hospital cannot afford aviation personnel fully dedicated to their EMS helicopter, should it be in the aeromedical helicopter business? Adding an additional pilot (and perhaps there should be four per helicopter at busy programs) does not automatically improve safety. But it goes a long way toward improving the quality of work and personal life - both factors affecting performance and judgment. 6) Should the development of safety programs be the responsibility of individual aeromedical programs or national organizations?
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HOSPITALAVIATION,MARCH1986
An Editorial Opinion... Underlying the success of the aeromedical helicopter concept was the marriage of a health care institution expert at providing medical care with an experienced helicopter operator expert at providing aviation services. It is this contractual team, at the program level, that must deal with the problem. The hospital (or sponsor) should work with the vendor of aviation services in establishing standards (some of which are outlined above). If additional resources are needed, the local entity has several directions in which to turn. The HA1 has developed a comprehensive safety manual for helicopter operations, and has a full-time safety director. The organization also has in-place an EMS committee established primarily for safety evaluation. (That committee has in its membership representatives from all the aeromedical organizations and is chaired by the manager of the largest aeromedical helicopter vendor). Other resources include a half-dozen professional aviation consulting firms, several of which are familiar with aeromedical operations. They offer comprehensive and objective operational safety audits or reviews. NEMSPA, representing more than 120 aeromedical pilots from the majority of hospital-based helicopter programs, has already published a landing zone safety pamphlet. In addition, the organization has in draft form both a pre-post accident plan and aeromedical operating standardization guidelines. ASHBEAMS and NFNA have already developed several guidelines and crew performance standards, and can assist in the crossover areas involving flight crew participation and ground crew orientation and related needs.
7) Should hospitals require aircraft operators to present in detail their safety program when responding to an invitation to bid for an aeromedicai service? It has already been established that each sponsor of an aeromedical program (with the assistance of industry associations and experts as required) should take the lead in enforcing operational, equipment and training standards to be required in bid specifications or other contract negotiations. The universal adoption and enforcement of improved standardization requirements is the only vehicle that will lead operators in a competitive bidding environment to develop or maintain viable safety and accident prevention programs, which will in turn help reduce aeromedical accident probability.
Summary From 1972 through the end of 1985, 83 % of all fatal aeromedical helicopter HOSPITAL AVIATION,MARCH 1986
accidents were attributed to "pilot error." Visibility (or the lack thereof) was definitely a measured complication observed in the statistics. Darkness and/or adverse weather were adverse factors in 93 % of these accidents. But pilot error is often only the last, albeit final event in a chain of events where operational protocols or other accepted practices may have created the proverbial "accident waiting for a place to happen." Based on the observation that there is a high correlation between darkness and/or adverse weather and pilot error accidents, Hospital Aviation poses that pilot error accidents can and must be reduced by providing the pilot with improvements in environment, skills and/or equipment with which to operate. Such improvements must result from administrative decisions. Environmental improvements may include (1) improved pilot scheduling to reduce fatigue and shift rotation, with the addition of a fourth pilot per helicopter on an active program; and (2) the adherence to responsible night weather minimums. Also on the list would be factors affecting fatigue or judgment, such as eating, smoking and drinking habits the night prior to duty. Improved skills may include (1) the requirement for an instrument rating for each pilot, and (2) maintaining instrument currency - both aimed at proficiency in spatial orientation for low visibility missions. A third factor would be increasing the number of check rides from annually to semi-annually, with an increase in quality by placing more emphasis on emergency and instrument procedures. Improved equipment might include (1) flight control stability augmentation, ("wing-leveler" or "autopilot") systems - to reduce pilot workload/overload, and (2) the utilization of twin-engine helicopters. It should be emphasized, however, that additional equipment will not compensate for. a faulty decision process that puts the pilot in a marginal condition in the first place. Hospital Aviation is aware that it is difficult to develop a set of standards that will fit every situation and find unanimous support. We are cognizant that differences in pilot skills, aircraft capabilities, and program geography can and should modify the basic rules. But it has been our observation that many of the accidents have resulted (at least in part) from the hesitation of hospital administrators, program directors, operating companies, pilots and transport teams to realize that accidents have, and will continue to happen to them if positive steps are not taken to minimize the classic problems. Accidents occur most often because of a disregard for operational policy, or a total lack of operational policy. Few of the foregoing recommendations
come without cost. But is that cost different in principle than the costs associated with the recertification and/or training received by physicians and nurses in the medical community? Do we want to continue to fly with pilots who received their last standardization and instrument training 15 years ago in Viet Nam? We don't fly helicopters that miss a 600-hour inspection; why fly with pilots who are not given the opportunity for preventive maintenance on their emergency procedures? But aside from increased training, scheduling, and helicopter equipment, perhaps the most important safeguard involves a simple question. In the past, the emphasis has been on justification by a pilot or crew as to why a particular mission was turned down or cancelled. Shouldn't this approach be emphatically reversed? Shouldn't pilots be required instead to justify the acceptance of any mission if it increases the risk of the flight crew? Only when missions and their associated risks are appropriately managed in light of current technology and prudent judgment will the accident rate of the aeromedical industry be turned around. And that day won't come any too soon.
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