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Maryland Air Ambulance Review Panel
Stephen Richey stephen.richey at gmail.comTue Nov 25 20:05:24 GMT 2008
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Cases where medical helicopters had problems with off-airport landings per the NTSB: * 12/1/2007 Talladega, AL* The pilot performed an off-airport landing in the helicopter, to pick up a patient for transport to a nearby hospital. During the subsequent takeoff, the helicopter's tail rotor struck a wire that was located about 30 feet above the ground, oriented perpendicular to its flight path. The pilot immediately landed without further incident. Neither the pilot, nor the crew were previously informed of the wire, which was not observed until just prior to contact. The helicopter sustained damage to the tail rotor, vertical stabilizer, and left aft storage compartment door. *8/9/2007 Ridgeville, SC* The pilot said that upon landing at the scene he kept the helicopter operating with him at the controls, while the medical crew attended to the patient. After loading the patient into the helicopter, the paramedic did a walk around inspection, entered the helicopter, and called out the before-takeoff-checklist, while voicing an alert to the pilot concerning overhanging trees on the port side of the helicopter. The pilot acknowledged, and told the crew that he intended to pick the helicopter up into a hover, slide to the right, and then perform a left pedal turn to exit the scene to the west. The pilot said that while performing a left pedal turn at a hover, a vibration occurred throughout the airframe, and he immediately set the helicopter back on the ground, facing west. An EMS technician on the ground who had been observing the helicopter, stated that after the patient had been loaded into the helicopter, the helicopter was lifted into about a 3-foot hover, and then began to rotate and face into the direction of the light wind, coming from the west. After the helicopter completed the rotation into the wind, the EMS technician stated that it then began to increase altitude, and as the altitude increased the tail rotor struck a small pine tree limb that stuck out about 1 to 2 feet into, and over the westbound traffic lane closest to the median. He said he heard the change in pitch to the sound of the helicopter's engine, and also saw the tail rotor begin a slight "wobbling." At this point the EMS technician said the helicopter was about 6 to 8 feet off the ground, and he believes that the pilot sensed that something was wrong with the helicopter, and set the helicopter down firmly on the curbside lane, facing west. An examination reveal no evidence of a preaccident mechanical failure or malfunction to the helicopter or any of its systems. *21 February 2005 Gentry, Arkansas* (Patient killed in crash) The setting and wind conditions contributed to the crash because it reduced the effectiveness of the tail rotor. *14 July 2004 Lake Louie, ID * After the medical evacuation flight arrived at its designated landing zone (6,500 feet mean sea level/MSL), an out-of-ground-effect hover was accomplished to verify the aircraft's performance. The power check was good and a positive rate of climb was noted. After landing and the crew had exited the aircraft, the pilot departed the area to locate a landing zone closer to the pickup point of the crew and patient. A landing zone at the 6,600 foot level (MSL) was located 3/8 of a mile closer to the patient pickup point. While waiting to load the patient the pilot determined a takeoff could be made based on his review of the aircraft's takeoff performance data. After completing an in-ground-effect power check and initiating a vertical climbout, the pilot confirmed the helicopter would clear a 100 foot tree line as it began to transition forward. After clearing the tree line the pilot detected the aircraft lose all lift as the helicopter began to settle toward the approaching trees. Applying the remaining power, the RPM warning sounded, prompting the pilot to reduce collective, but only to realize that he was descending into approaching obstacles. Right pedal was applied in an attempt to return to the original point of departure, however, the rotor RPM had still not completely recovered and the aircraft continued to descend. The aircraft impacted a boulder, and with the RPM now fully recovered, the helicopter jumped back into the air. The aircraft then rotated 180 degrees before the pilot performed a hover autorotation. During the maneuver the tail rotor had impacted a tree branch which resulted in an 8 inch chord wise gash to one of the tail rotor blades. The pilot felt that as the helicopter was clearing the tree line it entered a downwind condition, a condition which he didn't anticipate, resulting in a reduced power margin with which to overcome the loss of lift. A weather reporting station located 7 miles west-northwest of the accident site reported the wind was variable at 3 knots. The density altitude was calculated to be 8,898 feet. The pilot did not assert that any mechanical malfunctions precipitated the accident. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The failure of the pilot to maintain rotor rpm and his inadequate recovery from a bounced landing. Factors contributing to the accident included the tailwind condition and the tree. * 16 March 2003 Highland, Michigan* On March 16, 2003, at 2015 eastern standard time, a Bell 430 helicopter, N431UM, piloted by an airline transport pilot, was substantially damaged when the tail rotor impacted a roadway sign during an aerial taxi. The accident occurred on Highway M-59, east of US Highway 23, near Highland, Michigan. Visual meteorological conditions prevailed at the time of the accident. The medical evacuation flight was operating under the provisions of 14 CFR Part 135 and was not on a flight plan. The pilot was the sole occupant at the time of the accident. He reported no injuries. The flight departed the University of Michigan Medical Center Heliport (MI32), Ann Arbor, Michigan, at 1959 est, with the intention of returning to MI32 after picking up a patient. According to the pilot's statement, he overflew the area from west to east to review the landing site. He stated that he reversed course and approached the landing site from the east. Prior to touchdown the pilot reported he rotated the aircraft and landed on an easterly heading, at which point the medical crew departed the helicopter. The pilot decided to reposition the aircraft to face west for departure. After notifying local authorities and clearing the helcopter, he reported he began to taxi to the east. He stated he "cleared the tail to move left into the turn around along M-59. I started to move the aircraft which now was facing south into M-59 ... when the tail rotor hit a steel reflector post. The aircraft became airborne to around five or six feet when I lowered the collective and rolled the throttles to idle to stop the aircraft rotation." The aircraft impacted on the left rear skid first and came to rest one-hundred eightly degrees from its initial heading. A post-accident examination revealed the tail rotor and gearbox had departed the helicopter. The pilot reported there were no mechanical malfunctions with the helicopter prior to the accident. *18 August 2001 Vinton, CA* The pilot of the med-vac helicopter reported that, during liftoff at the remote site, he encountered a loss of visual reference due to a "brown out" condition created by blowing dust at 3 feet agl. He then attempted to land the helicopter without any visual reference; however, the right skid contacted the ground first. A rolling motion to the left was created and, after the left skid contacted the ground, a dynamic rollover ensued. The helicopter came to rest on its left side. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's selection of an unsuitable landing site, which caused "brown-out" conditions during departure liftoff and resulted in loss of control of the helicopter. * 14 October 2001 Grand Canyon, AZ* During the aeromedical evacuation of a seriously injured patient, the helicopter pilot attempted to takeoff from a clearing surrounded by trees and high elevation terrain. Also on board the helicopter were a paramedic and a flight nurse. The crewmembers indicated that no tree branches were closer than 8 to 20 feet from the helicopter as it gained between 80 and 100 feet above the terrain. As the pilot turned into the light wind, the tail rotor lost effectiveness and the helicopter started yawing uncontrollably in a clockwise direction. Due to the lack of climb performance in the high density altitude (approximately 8,850 feet) and heavy weight condition, the pilot made a forced landing in the underlying terrain during which it impacted trees. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's in-flight loss of control during liftoff due to his improper planning and decisions. Related factors were the high density altitude and helicopter weight condition, and the lack of a suitable takeoff area. *17 November 1999 Neihart, MT* The pilot reported that, due to trees directly in front of him for the departure from a remote site located near ski lift towers, he elected to turn the nose of the helicopter 45 to 50 degrees to the left, hover over to an open area, and depart downslope building airspeed and altitude. After the helicopter moved to the left about 20 to 30 feet, the pilot felt the tail of the helicopter rotate abruptly to the left. The pilot applied left pedal which slowed, but did not stop the rotation. The pilot applied cyclic control to return to the landing zone. During the maneuver, the helicopter drifted over to one of the ski lift towers, striking the tail rotor on the tower. The rotation increased, and the pilot closed the throttle and utilized collective to cushion the landing which was hard. The pilot reported that there were no mechanical failures or malfunctions with the helicopter at the time of the accident. Shortly after the accident, as the pilot was waiting for company personnel to arrive, he noted that at 10 to 15 minute intervals, the wind gusts would become stronger for a short period of time, then die down. The pilot reported that the wind was from 180 degrees at five knots, gusting to 15 knots. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Clearance from an object was not maintained. Gusting wind conditions was a factor. *13 February 1999 Hockley, Texas* The helicopter impacted power lines while departing from an automobile accident scene. The helicopter was part of a two aircraft team dispatched to the scene of the automobile accident. During the landing approach, the pilot noticed the power lines running parallel to the road; however, he did not consider them to be an unusual hazard at the time. After the passengers were loaded into the helicopter, the pilot took off, drifted toward the wires, and impacted the power lines. The pilot then landed the helicopter in an adjacent field. The pilot stated that at the time the helicopter impacted the wires 'the sun was shining directly into the aircraft' and that 'trash was blowing around.' Another helicopter was dispatched to the scene of the accident to transport the patients to the hospital. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to maintain clearance with the power lines. A factor was the sunglare reducing the pilot's visibility. *29 November 1998 Idaho City, Idaho* The McDonnell Douglas MD-900 medevac helicopter was dispatched to a car accident at a site characterized by high terrain and high trees. Prior to landing, the pilot requested information about wires and was advised by ground personnel that 'there were none.' Subsequent to landing, the pilot examined the landing site and proposed departure route for wires, and reportedly observed none. The departure from the site was conducted under dusk to dark night conditions. While climbing out vertically due to the narrow canyon conditions at the site, the helicopter struck unmarked transmission lines approximately 150 feet above ground. The pilot then determined that the helicopter was controllable and displayed no unusual flight characteristics, and chose to proceed to his destination. Post-flight examination revealed crazing of the windscreen and damage to four of the five main rotor blades requiring major repair/replacement. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot-in-command's not obtaining/maintaining clearance with the unmarked transmission lines. Contributing factors were environmental (dusk) conditions, the transmission lines, and both the pilot-in-command and the ground personnel not identifying the existence of the hazardous condition (high wires). =========================== Those are the cases that I found in a quick review of the past 10 years worth of crashes. Luckily there was only one fatality as a result of these crashes, but still there are lessons to be learned here. There are numerous additional cases where helicopters not on medical flights have had accidents under similar circumstances and we would be well advised to include those in the review of whether off-airport landings are really a good idea, especially given the minimal benefit offered to patients by helicopter transport in most circumstances. This list is also limited to the Part 135 operations- in other words, which for the most part are only those where there was a patient on board at the time of the incident. This list also excludes those incidents where the primary cause was a mechanical problem (either immediately after departing an improvised LZ or on approach to one) and the lack of suitable area to put the helicopter down in contributed to the problem. I will put together a list of the Part 91 incidents which include those incidents where there was no patient on board, but this may take a few days as there are far more cases of helicopter crashes to go through and I am moving tomorrow back to Indiana. -- Stephen L. Richey, CRT Aviation Injury Research Project Leader Saginaw Valley State University Work E-mail: slrichey at svsu.edu Home Office Phone: 248-366-4452 "Hier stehe ich. Ich kann nicht anders. Gott helfe mir. Amen."- Martin Luther, before the Diet of Worms, 16. April 1521
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