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This page is used to collect in-flight experiences that have provided lessons that may be of benefit to all pilots in the air-medical transport industry. This kind of sharing is typical within any given air-medical transport program. NEMSPA wants to use this forum to place that exchange of wisdom on a national level.
We recognize that the great majority of such lessons happen when we make mistakes. This is a safe place to share such lapses in an anonymous manner. Although you can disclose any information you want, feel free to "sanitize" your narratives to avoid identifying people or places. We are only concerned with using our experiences to help others avoid making the same mistakes. Of particular interest are accounts of problems that occurred due to faulty CRM or Situational Awareness. By sharing these events in this space, you can literally save lives.
This is a new feature of the NEMSPA website, so only a few submissions have been posted, so far. As each narrative is submitted, it will be reviewed by the NEMSPA Board of Directors for "appropriate content and language". After approval, it will be added to this page for the consideration and edification of all interested website visitors. Selected stories may also be published in future issues of Air Net, the NEMSPA newsletter. To you who have already shared your experiences here we say, "Thank you, thank you."
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| Submission Date | Narrative |
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| 2006-12-08 | Years ago, on the last hour of my last night shift, I took a VFR flight with weather above minimums to the northwest of my southeast coastal city. As I sat on the LZ - a two lane road - and watched it get light outside, I realized that wisps of fog were coming up out of the trees. I listened to an airliner inbound to my city airport (between me and my hospital) mention weather west of the airport, moving east, into my route back to the hospital. We took extra time loading two critical patients. It was a big bloody mess. When I took off, the weather had deteriorated, but was still above program minimums. As I proceeded toward my base, and got very close to the airport, the weather got worse. I could tell from conversation from the back that the patients were in very bad shape, and I felt a responsibility to get them to our hospital. I got a special VFR clearance from the tower. As I crossed over the airport, the controller verified my intentions. I wanted to get the patients to the hospital, just a few miles further. A pilot in another helicopter called on the tower frequency and advised that the weather east of the hospital was okay. I pressed on. The ceiling and visibility got really low. I had SPIFR experience, and felt a strong urge to climb, get a clearance, and shoot an approach. I could hear the nurse and the medic, and the patients were both "circling the drain". I figured that if I delayed their treatment going IFR, they would die. Just a couple of miles further. I went IMC at 300 feet and 60 knots. I transitioned to instruments, and tried to remember where the towers stood between the airport and the hospital. I passed over a military field - I was off the courseline. I declared an emergency and landed. Both patients, victims of a vehicle collision died shortly after arriving at the hospital. As I drove home, I felt like a total loser - not because the patients died, but because I made so many bad decisions. 1. The weather was above minimums for the flight, but the temperature and dewpoint were close. I should have anticipated fog and been ready to abort. 2. When I saw the fog in the trees, I should have stopped the train right there on the scene. The nurse and paramedic could have gone by ground with the patients. 3. When I heard the airliner mention the weather... see #2 above. 4. When I had to get a special VFR clearance, I should have just landed. Right where I was. A helicopter can do that. 5. When I flew over a perfectly good airport, I should have landed there. Airports are great places to land. 6. I should not have pressed on because another pilot in another location told me the weather was good where he was - where I was it was bad. 7. When I went IMC, I should have performed procedures which I have trained on hundreds of times and am comfortable doing, instead I pressed on and hoped for the best. 8. Somehow, for some reason, I put the fate of two strangers ahead of that of two friends who I worked with all the time. The two patients were already injured. I didn't do that to them. If I did one smart thing, it was landing at the military field instead of continuing. I was very, very lucky, since there are towers where I was. I must have flown by some of them. I am embarassed to be telling this story. When I did this I was a 13 year pilot with 3000 hours, and had already done lots of dumb things (and should have known better) If it stops you from doing what I did it is worth it. |
| 2006-11-20 | I was once sent with my medical crew to a small meadow nestled between high mountain peaks. The purpose of the flight was to conduct helicopter safety training with sheriff’s department rescue personnel and other first responders in an adjacent county. I descended below the nearby peaks and circled the LZ to look for any obstructions along the final approach path and to pick a touchdown point. After flying about ¾ of a right-hand circle while peering intently through the pilot’s door window, the flight nurse in the co-pilot’s seat asked me, “Have you got that mountain at twelve o’clock”? I looked up and increased the bank angle and replied, “Yeah, I’m watching it. No Problem”. In fact, I’m pretty sure I would have glanced up in another second or two and noticed how close my flight path was going to bring us to the mountainside. Or, if I didn’t look up, we would probably have missed the mountain anyway… or, maybe not. Obviously a more professional (and grown up) response would have been, “Thanks, Denise, I’ll be sure we miss it”. This was an example of a loss of awareness (failure to perceive the situation) caused by a distracting task, the LZ reconnaissance. It was also an example of good crew resource management on the part of the flight nurse and less-than-stellar CRM on my part. |
| 2007-02-24 | Most pilots won’t admit it, but we read testimonials like this hoping to learn from them. We think as we are reading “Have I been in that situation or similar to it and what would I have done? One of my favorite sayings to pilots that come back and are talking about an experience is: “OK you have been there - done that, but did you learn from it and how will you prevent it from happening again”? I’m no different from any other helicopter pilot out there, so yes I’ve made mistakes and am glad to be able to still be here to talk about it. We picked up several crash victims from a vehicle that rolled down the side of a mountain. The weather was above minimums at the hospital and reported to be so for 2 hours after our ETA. The medics said the patients were stable so we weren’t pushed by their condition, yet didn’t waste any time or collective. As we approached within 20 miles of the hospital, pilot reports were coming in that the weather was deteriorating quickly. After checking with ATC and our operations, the bad weather was confirmed. Without an alternate hospital we continued hoping to “beat the weather” (now, don’t tell me you haven’t done that). The closer we got, the worse it got. Guess what we had forgotten? Yeah, your right, the NOTAMS, and of course ATC asked us the same when we asked for an approach to the area near the hospital. I still had a few functioning brain cells, so I decided to divert to our base and have them ground transport to the hospital, since it was about 10 miles from the hospital. Now here it comes, ready? The weather was below minimums at base, no instrument approach available and if that wasn’t enough, the medic reported that some of his life support gear was malfunctioning. Well, rather than turn back to better weather, I was so close I decided to hug the Interstate that I knew so well and make a “hope-I-see-the-airfield” approach (you know you’ve been there, now don’t you if you have flown any actual IFR). I was trimming the trees and got within a mile of the approach end ok, but tower told me I was not cleared to land. Hmmmm... Weather very near zero and knew I could see the airfield, “Tower, sorry your coming in garbled must make an emergency visual approach. I have the runway in site (kind of) and will contact you after I’m on the ground. Please get Ambulance ready to transport 3 critical souls to ABC hospital”. Ok, I know, I know, but what was I to do? With equipment failing, no other options ( I got myself into this mess). We landed and patients were transferred. When I finally got to a cup of coffee, I was standing by our local-area map, sipping my coffee and looking at the interstate which I had followed, and which I knew so well. When I suddenly realized that I had flown under (yes, UNDER) a set of high-tension lines across the interstate. I had one of those “Oh my God” feelings. Luckily there was a chair nearby, and I think I burned my mouth when I gulped the full cup of hot coffee down. I could just imagine my helicopter, crew, and patients, dangling from those wires and the accident board saying, “What the @&*$! was he doing flying so low and trying to stay under the weather? How many hours did this guy have?” I’ll let you be the critics and determine the 5 mistakes I made. No I never did tell anyone about flying under the wires, but you can bet I made sure to put them on my map and am very aware of where they are on all my flights now. Yes I’m lucky to be here writing about this. I hope you also learn something from it, I know I did!! Be safe and God Bless. |
| 2007-09-09 | COMMUNICATION IS SO IMPORTANT. Several years ago I was inbound to a rooftop hospital helipad with two nurses and a critical pediatric patient on board. As I transitioned through a local TCA, the nurses were coordinating with our communications center while I coordinated with the control tower so I could fly low-level beneath a string of commercial traffic on final approach. The "girls" radio transmissions were making it hard to hear the tower controller, so I reached down and hit the switch on my ICS box to isolate me from their transmissions. We landed on the helipad and I brought both engines to idle to start the cool-down. I grabbed my clipboard and started to log the details of the flight during the cooldown. Then I dropped my pencil on the floor and leaned over to pick it up. The clipboard on my lap pushed against the cyclic and deflected it from the neutral position. Before I could straighten up, one of the nurses began screaming at someone outside of the aircraft. I looked up and was horrified to see the hospital security guard frozen in the act of pushing the gurney beneath the tips of the rotor system. Half of the gurney was beneath the rotor disk, but the security guard was still just beyond the tips, which was a good thing since I had deflected the rotor disk down to about the level of his eyebrows. I leveled the disk as the nurses got out of the aircraft and then ushered the guard in to hot offload the patient. Hot offloads are the exception rather than the rule and they are never done without prior coordination. Later, back in our quarters, I began to firmly "counsel" my two team mates about not informing me that they were going to hot offload. They stopped me and reminded me that the hot offload had been coordinated with our comm center who then called the receiving hospital to inform the security office there of our intent. Our pilots normally monitor transmissions between medical crew and the comm center, but I had isolated my ICS box from theirs. Two mistakes here: The minor one was theirs for not verbally confirming the hot offload plan with me. The major one was all mine for not informing them that I was going to isolate my ICS system from theirs. Our SOP now requires rotor pilots to inform the crew if they are going to "turn them off". |
| 2008-03-01 | We landed on the main hospital pad on street level around 2 AM and off loaded our patient. I shutdown the aircraft and proceeded to refuel while the nurse and medic were inside the hospital with the patient. I heard over the radio that another company helicopter was inbound for landing to the same hospital. SOP was for the incoming helicopter to land on the adjacent auxiliary pad if the main pad was occupied. A few minutes later I saw the company aircraft turn final for landing as I finished refueling. I noticed that the incoming helicopter was lining up on the main pad instead of the adjacent auxiliary pad so I began waving my flashlight incase they didn’t see me. Before I knew it they were on short final and definitely lined up for the main pad which I was on. At that point I stopped refueling and quickly cleared the pad. As I turned back from a safer distance they landed to the right of my aircraft, clearing it by less then 5-10 ft. They shutdown and unloaded their patient, as I approached their helicopter and asked the other pilot what the beep was he doing. He looked at me and said with a blank stare “I didn’t see your helicopter at all”. It is common practice to cock the nose out to the left so the pilot has better visibility, this placed my aircraft in a blindspot. Lessons Learned: always confirm your landing area is clear with a search light, develop better communication procedures with dispatchers as to whether the main pad is occupied, clear the main pad and refuel on the auxiliary pad. In hind site I should have quickly turned on my aircraft lights or called the dispatchers to ensure they knew we were still on the main pad. Very luckily, there was no damage to either aircraft. |
| 4662 | 2006-11-22 |