Towards safer EMS Helicopter Operations
Outline
TOWARDS SAFER E.M.S. HELICOPTER OPERATIONS
Blair Munford, BMedSc, MB,ChB, FANZCA
Senior Flight Physician & former Medical Director
NRMA CareFlight/NSW Medical Retrieval Service
Westmead Hospital, Sydney, Australia
Air medical accidents are a longstanding phenomenon:
Scope of the Problem
NZ & Australian HEMS:
– 7-10 (NZ) & 20-28 (Aust) EMS helicopters
– 7+ HEMS accidents in past 10 years involving hull loss & death or injury (crew +/- patients)
USA 1993-2002:
– Approx 230 programs with 400 helicopters
– 68 major accidents (hull loss)
– Including 30 fatal accidents (av 2.5 fatalities)
US HEMS Accidents 1972 -2002
The good news:
Patient death rate in HEMS accidents(US)
= 0.76/100,000 patients flown
Compared to:
Patient death rate from adverse event or medical error in hospital:
= 131 to 292/100,000 patients
(Range of studies)
The bad news . . .
Relative risks of death for HEMS crew
(Death rate per hour of activity)
Rock climbing 1:25,000
HEMS flying 1:32,900
Skydiving 1:50,000
Motorcycling 1:55,000
Skiing 1:340,000
Car driving: 1:1,190,000
The tragic story of a HEMS accident:
24th July 2000, Rockhamptom, Qld.
Bell 206L Longranger, community supported EMS helicopter
2326 callout for 2 yr old child with croup, 90NM away.
Departure 2340. Crew pilot, AO/crewman, paramedic AO (3)
Departed scene w/crew plus patient & mother (=5 PoB)
Enroute diversion (due insufficient fuel) to halfway location
Fog (as per forecast) at attempted LZ location
Three landing attempts aborted due visibility
Further attempt enforced by low fuel state
Aircraft struck ground in steep banking dive
No survivors
Contributing factors
It’s easy to be wise after the event, but:
Insufficient fuel
Probable failure to check/heed weather
Excessive haste
Possible pressure from perceived urgency
Fatigue/sleep inertia
Poor flight planning
Inadequate medical crewing
Poor cockpit resource management
Some more sorry tales:
Helicopter on approach to (previously used) scene LZ
Struck wire – known to be there but not taken into account
Helicopter on night over-water flight to accident on island
Lost horizon reference & hit sea – no survivors.
Fully loaded helicopter lifting off from mountain HLS
Overloaded for temp/altitude – insufficient power when lifting out of ground effect – lost rotor speed & crashed.
Helicopter on night low level VFR flight
Navigational error – flew into trees on rising ground
Factors in HEMS Accidents
Weather
– Including darkness
Wires
– & other obstacles/terrain
We the people
– The human factor
Turning the Corner
“Aviation, even EMS aviation is not inherently dangerous . . .
. . . it is however, inherently unforgiving of mistakes”
“There are old pilots and there are bold pilots – but there are not any
old & bold pilots”
99.9% Safe?
If each HEMS flies 1 mission per day:
Then can expect to have 1 major crash/3 HEMS programs/year
If airlines worked on 99.9% safety:
Would have 18 international flights crash each day!
Human Risk Factors in HEMS Accidents
Complacency – “the silent killer”
Risk taking behaviour
Lack of “safety culture”
Pressure to complete task
Excessive haste/poor planning
Inadequate training
Fatigue/inertia
Poor crew resource management
So, just what exactly is this Crew Resource Management (CRM) business?
Crew Resource Management
Defined as: “Effective management of all available resources to maintain a common frame of reference and safety goal.”
2000 Air Medical Safety Summit (USA) identified CRM and related training as the number one priority.
CRM – the prerequisites
To have crew resource management you first need to have a crew
– Remember, crew resources are not necessarily only in the aircraft
Safety is everyone’s business
CRM is not “cockpit communism”
– One captaincy but universal airmanship
– Leadership complemented by followership
Remember: Safety begins with “I”.
RPT versus HEMS
AIRLINE SERVICES
Scheduled flights
Planned in advance
Designated & well equipped airports
Wide array of navaids
Close air traffic control
H.E.M.S. OPERATIONS
Unscheduled flights
Rapid decision making & planning required
Small helipads & unimproved LZs
Limited navaids
Predominantly “OCTA”
“Seven Pillars of CRM”
Teamwork
Effective communication
Workload management
Systematic decision making
Situational awareness
Stress avoidance/management
Practice & simulation
“Crew Resource management is the human component of active safety”
“The Safety Triangle”
PRO-ACTIVE SAFETY INITIATIVES
Safety aware management
Training for all crew in CRM
Designated Safety Pilot
Safety incident reporting & evaluation
Check & Training Program
Simulator training (flight crew)
HUET training if applicable (all crew)
Promulgation of “safety culture”
Active (operational) Safety
Crew resource management
Multi-crewing (co-pilot or aircrewman)
Non fatigued crew
IFR capability & currency
Advanced medical capabilities
Proper mission planning
– including abort drill/backup plan
Remember: Declining a flight on safety grounds is a valid risk management
“Nobody ever crashed an aircraft by not flying it”.
Are Two Engines Better Than One?
Two engines will not:
Stop you from hitting wires
Save you from spatial disorientation
Stop you running out of fuel
Save you from tail or main rotor failure
Two engines may:
Offer IFR capability
Allow carriage of an aircrewman or copilot
Allow fitting of extra navaids & safety gear
Allow flyaway in some circumstances in the event of failure of one engine.
What’s so great about IFR?
IFR stands for Instrument Flight Rules
Refers to capability to fly “blind” on instruments
Requires an autopilot, navigational aids, and a rated pilot (second pilot or ACM desirable).
Will allow completion of some additional flights
BUT
Is not a panacea - flights still require VFR (visual) conditions for takeoff/landing.
. . . However:
What IFR capability can do is allow transition to instruments in the event of spatial disorientation; or inadvertent or forced entry into IMC (cloud)
The IFR option:
Passive Safety Initiatives
(surviving when all else fails!)
Helmets/full harnesses
Fore/aft facing seats
– energy absorbing type if possible
Crashworthy cabin layout
– No loose objects!!!
HUET & egress/survival training
ELT beacons
– aircraft & personal
Survival pack/gear
New Developments in Safety
More & better GPS utilisation
Wire detection systems
Night vision goggles
Better crashworthiness
JAR Ops 3 & beyond
But who is going to design us a better human being to use them?
“But isn’t this all going to
be too expensive?”
If you think safety is too expensive, have you checked out the cost of the alternatives recently:
Human lives?
Aircraft replacement?
Legal liability?
Cost Saving Safety
Currently HEMS in NZ are:
Too numerous
Over-utilised
Inappropriately funded
In need of a systemic overhaul
With fewer HEMS we can afford better (clinical & safety) standards
My Vision for HEMS:
Fewer HEMS services
– Analogous to trauma centres
Multi-crew IFR capable 3-5 tonne class twin engined helicopters
Proper staffing roster 24/7.
Mandatory safety program & audit
Critical care clinical team (with)
Non-helicopter (i.e. road) backup transport
“Those who do not learn from history are doomed to repeat it.”
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Ministry of Health
