Aeromedical accidents

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With all due respect, the problems have largely been identified and the solutions are fairly obvious. All that is lacking is the will to embrace these solutions.

It is a bit like road trauma. For many years, it was obvious to all that 3 of the most significant factors responsible for road fatalities were alcohol, speeding, and inadequate passenger restraints. Yet how many years went by and how many tens of thousands died because assorted vested interests opposed the necessary changes? 

I urge anyone interested in this to read "Helicopter EMS, Part II" in the current (October 2008) edition of Business and Commercial Aviation. This article looks at 369 ASRS (Aviation Safety Reporting System) reports, and identifies the most common factors.

1. VFR-only helicopters. Unplanned entry of VFR helicopters into IMC (Instrument Meteorological Conditions) can occur easily in marginal weather and at night. Unfortunately, inadvertent entry into IMC is often quickly fatal - regardless of the experience of the pilot. In 59 HEMS crashes in which the pilots had a median of 5,500 flight hours (ie pretty experienced), there was an average interval of just 34 seconds between entry into IMC and impact with the ground at high speed! With this in mind, it is concerning that the FAA statistics show that the largest growth segment in EMS aviation is VFR-only helicopters (presumably reflecting financial pressures). 

2. Flying in poor or marginal weather conditions. Sometimes a flight was accepted in full knowledge that the weather was poor. However, it was also common for pilots to lack precise or up-to-date weather information prior to departure, and thus finding "unforecast deteriorating conditions" en route. Regardless, flying in poor weather obviously increases the risk of inadvertent entry into IMC.

3. Night operations. 78% of inadvertent entry into IMC took place at night - when cloud or fog are often not seen until it is too late. Also, human performance is inevitably degraded at night time. 

4. Scene operations - for a variety of reasons, these are far more dangerous than interhospital transfers.

5. Excessive pilot workload - present in 84% of the ASRS reports. EMS helicopters are often single pilot, and an autopilot is not routine. Distances involved are frequently relatively short - thus with little time between taking off and landing. Ambiguity about the exact location, uncertainty about a suitable landing site, and the need to monitor and communicate over multiple radio channels adds to the workload and stress. The pilot frequently faces distractions from multiple competing inputs - > 10% of reports indicated that "distraction was so pronounced that aircraft control degraded to the point at which safety was jeopardized".

6. Lack of readily available safety equipment such as TAWS (terrain awareness and warning system - which warns of a potential collision with the ground), TCAS (traffic alert and collision avoidance system - which warns of a potential mid-air collision, and gives instructions to the pilot how to manoeuvre to avoid the collision) and night vision goggles (once you have used these, you will be reluctant to ever fly at night again without them). In 2006, the NTSB recommended that the FAA require all HEMS operators to fit their aircraft with TAWS. Unfortunately this has not yet eventuated. While Maryland had recently fitted TAWS to several of their aircraft, it was apparently not fitted to the one that crashed 2 weeks ago. 

7. Management pressures. A 2007 investigation by the US Government Accountability Office found that financial pressures have increased competition in certain areas, and possibly increased the frequency of unsafe practices. These unsafe practices included:
a) Helicopter shopping - defined by the FAA as the practice of calling various operators until one agrees to accept a flight assignment. 
b) Call jumping - where an operator responds to an incident without being dispatched
c) pressure (explicit or implicit) from management on pilots to accept missions

8. The "hurry up syndrome" - a pressure that HEMS pilots obviously are frequently exposed to. Judgement is critically impaired in the face of time pressure - a shortage of time increases the risk of human error by a factor of 11.

9. The understandable human tendency to push the envelope or cut corners when exposed to a patient in a critical condition. While people advocate isolating the pilot from medical information to mitigate this threat, this is not realistic - a critically ill or injured patient looks critically ill or injured, and it will be clearly obvious to the pilot whenever the medical crew are particularly stressed or anxious. It is perhaps better for all crew to have insight into this inevitable process, and to adopt various measures to mitigate it. 

So the solutions:
1. Better equipped helicopters - IFR capable, with all the latest bells and whistles
2. Fewer operators - will follow on from above as not everyone will be able to clear the high bar if it is raised. Natural selection should mean that the most marginal operators will go.
3. Formalized pre-determined dispatch procedures, which remove some of the difficult and error prone decision making from the pilot in the heat of the moment
4. Mandate enough time prior to departure for flight planning and to obtain accurate weather information
5. Be very careful with scene and night operations. Maybe all operators should not do this particularly high risk work.
6. Try as much as possible to ensure that the only flights conducted are those medically necessary. This is essentially impossible for scene responses - where limited information means that a degree of over-triage is appropriate and inevitable. It is however somewhat easier to do for interhospital transfers. 

Cheers

Steve Walker
Emergency Physician
CareFlight
Sydney Australia


Let me try this another way
If there are pilot pressures leading to unsafe operations, then it needs to be stopped.
If there are unsafe helicopters, they need to be pulled from the sky.

Reducing operations is the WRONG way to approach this.
Fewer operations, under unsafe conditions, will STILL result in dead people.

These are our colleagues, and friends, out there.
The attention of all involved needs to be fixing the SAFETY issues, not diverted by medical judgment call questions.
If there is an unsafe medical device on the market, we don't approach the problem by reducing it's indications, we remove it from the market.

There must be ONLY one individual able to decide if a flight goes - that's the pilot (who also is responsible for deciding of the aircraft is airworthy, BTW.) 
It would be nice if the folks doing triage were always right...it would be nice if the referring and accepting physician on a transfer were always right... but helicopters are fairly safe so when the medical side of the equation providers are wrong, the risk should still not exceed potential benefit.

This is EXACTLY analogous to surgery - there is ONE person who decides if surgery is a good idea - the surgeon.
If that surgeon has excessive bad outcomes, then the surgeon gets looked at.
You can't have a regulatory panel telling surgeons when they can operate.
You shouldn't try to reduce surgical mortality by allowing unsafe practices but reducing surgeries. 
You can't have someone other than the pilot decide to fly or not fly, once the medical system asks if the flight can be made.

We need to speak with ONE voice, and NOT about utilization - we need to speak about unsafe operations.
I would rather see all aeormedical transfers stopped pending safety reviews than have us delude ourselves, and the FAA/NTSB, that the medical side of the operation is using poor judgment and that is somehow responsible for crashes.  It is NOT!
AFTER the crashes stop, THEN we can address appropriate use concerns.

If we want to facilitate profit motivated operators by making aeromedical operations more complex and confusing to regulators and safety people, continue to talk about evaluating appropriateness of operations. 
If you want our colleagues to be alive, demand safe flying....
This is NOT impossible....

Lorick




 
 
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