The Article That Started It All - EMS Flight Crew

I wrote this about a year ago in response to what I felt was a culture of apathetic attitudes toward safety among many levels of the air medical industry. My frustration grew over time and failed attempts to proffer change. I became convinced that it would be useful if there was a place where people from all over, in the air medical community could learn from one another's experiences through the supportive exchange of information, ideas and lessons learned. Perhaps many of us were having the same safety challenges and there were lessons out there that could benefit us. My attitude evolved and I found myself in shift briefings telling the crews that on this shift, on this day, at this base the only people who will determine whether it's safe to begin, continue or complete any mission is the group of 3 professionals that are right here, right now and no one else.

It's been almost 8 months since we launched and while it's a continual work in progress, I hope you have and will continue to enjoy, contribute to and learn from some part of our content. Please always put safety above all else.

Rule #1- Go home at the end of your shift.

When I look back at the tragedy’s our industry experienced in 2008 I mourn the loss of our colleagues, but I also try and look for clues. What can we learn about what happened that will help us operate more safely. As an active EMS helicopter pilot working for a busy program I spend time reviewing accident reports in hopes of gleaning some useful lessons to apply to our operations so that we will be able to always comply with Rule #1.

Not having been on any of the accident aircraft, no one can know exactly what happened. What sequence of events lead to the accident. Where might they have made a different choice and how might that have affected the outcome. I feel it can be valuable to ask ‘what if ‘, to attempt to piece together the possible links broken in the safety chain. Not what if they did ‘this’ or ‘that’ differently, rather what if we were confronted with ‘this’ event or encountered ‘that’ situation. How would we address it? What are our options and alternatives? As has been proven in the past it is usually a series of events, that when allowed to occur in continuum, have a catastrophic ending. If any one event were removed, then the results might have been much different.

One thing I have observed about myself is that it takes a great deal of energy for me to resist the urge to allow ego and pride not to play a part in decisions that I make. Perhaps I allow myself a much less detailed walk around inspection of the aircraft before climbing in when I know it’s a scene call just 7 miles away and dispatch let it slip that a child was involved who is the same age as my daughter, versus a hospital transfer 126 miles away to pick up a 96 year old DNR. It could be that time when I miss the tail rotor tie downs installed despite walking right past them. There seems to be a sense of tunnel vision that develops when adrenalin starts pumping and the nature of what we do supersedes the responsibility with which we are tasked.

I can always do better. After every flight I critique lift off to landing and I’ve never come away thinking that there was not some improvement that I could have made. I think that is a good starting point for discussion. Acknowledge mistakes to your crews when and if they occur. You build substantially more credibility by acknowledging what you do not know and then finding the correct information versus making something up. Open and honest dialogue with your crews builds trust and encourages them to be engaged in the process. It might very well one day be the paramedic in the back who calls out the crossing wires on approach that saves your life (as happened here a few weeks ago).

Apathy, complacency and fatigue are killers.. Who among us can say that we are as sharp and vigilant on our fourth flight of the night lifting off at 5 a.m. as we were on our first lift off 11 hours earlier? You have to be or don’t go! It is so easy to take as routine the business of departing the base on a call. There are no routine departures and every liftoff may very well be your last unless all of you aboard are alert, engaged and communicating. It is paramount that you demand this every time.

Unfortunately I think it is human nature that the more we get away with doing something, no matter how dangerous the more comfortable we become with it. While the pilot will ultimately bare the responsibility if something goes wrong, there are no ranks aboard an EMS helicopter, each one of you has the duty to cancel or abort a mission when the focus of what you are doing, safely operating in an aircraft, takes a back seat to some secondary task.

You do the patient no good whatsoever to pick them up from that accident scene only to kill them in a helicopter crash.

In recent months I have taken a more active role in briefings. Encouraging crews to be engaged and communicate how they would respond to this situation or that scenario and one thing I discovered is that very few had any plan of action for their own survival. Some had a blind trust in their pilots; flattering but dumb. Some were comfortable sleeping on the out bound legs, a gross dereliction of their responsibilities as fellow crew. Many if not most were ambiguous about expressing their being ‘uncomfortable’ with current weather, fuel status, cruising altitudes, LZ’s or any number of other events that might be considered less than safe operating practices. I tell my crews that my job during the next 12 hours is to kill them in a horrific helicopter crash and their only job for the shift is to not let me. Harsh, morbid, rude and not well received by some, but it is a wake up call for them and me, to not strap on a 9000 pound aircraft, and defy the laws of gravity without truly respecting the potential of what we are doing. While I have no way of knowing what happened aboard any of those helicopters before they became statistics last year, I would bet that not one crew member on any one of those aircraft, when the call came in walked out of their bases and got on board their respective helicopters thinking that this was going to be the last flight of their lives ,that when they left for work that day they had seen their families for the last time or that in X minutes they would be dead.

My recommendations:

Work methodically, with purpose and constantly evaluate yourself and the manner in which you perform your duties. Seek out every opportunity to learn, practice, mentor and contribute to the safe operation of this wonderful industry we work in. Strive to be a true aviation professional.

Acknowledge every instance you find yourself feeling rushed and be willing to make the unpopular decisions to delay, cancel or abort any mission when you find your focus is lost or you are not operating at 100%. Everyone must be on the same page and respect the task at hand. Communicate before, during and after a flight.

Utilize all technological advancements available, but remember that they don’t always work, sometimes fail and should never be relied on. That crop duster that just cut in front of you will not set off your TCAS since they generally don’t carry transponders. Work on your scan. See and Avoid!

Engage your crews, they are a resource and might one day help you follow Rule #1. Use the empty legs to propose scenarios and get them to engage and take a position. I sometimes verbally beat up my medical crew because they answer questions with “ I’d probably…”, “ I think I’d…”, “I might…” and various other non-committal language when I put them in scenarios that are potentially unsafe. I force them to take an active role. It is to every ones benefit and will make them more effective team members in the future. The life they save on duty that day might be yours.

Don’t ever allow ‘get home-itis’ to play a part in decisions. Fight this urge! Many times I’ve read reports of aircraft with chip lights or other mechanical discrepancies flying past approved landing areas because home base was only a few miles further or shift change was near. Unfortunately every time someone gets away with something like that it makes them more bold and brazen the next time. No one likes to get stuck somewhere, have to ground transport or spend the night away from base/home, but the alternative is far less appealing.

Respect the weather! Our program is an active SPIFR program and we utilize that capability regularly. I can tell you that to be proficient you must regularly practice. In my opinion a semi-annual check ride with Foggles simulating IMC and getting out of IIMC is not sufficient to give you the necessary skill set to safely control a helicopter without visual references. Stay out of and away from weather you and your aircraft are not rated for! Be willing to swallow your pride and put it down safely in a field versus pushing on in hopes of improving conditions. Live to fly another day. Take pride and ego out of the equation.

7. Don’t allow patient information or condition to enter in to your decision.
Best intentions don’t always serve the greater good.

8. Create and administer procedures to deal with fatigue. The best days sleep seldom regenerates like a good nights rest. Night work requires day sleep and studies show that due to circadian factors day sleep is significantly shortened and often disrupted. Night work can result in acute sleep loss, creation of sleep debt and circadian disruption. Sleep is the most important factor to promote performance, alertness and safety (Mark R.Rosekind Ph.D. Managing Fatigue in EMS Operations). This is an area that needs to be acknowledged at the highest levels of the respective programs and receive full support down the line. No one should fear repercussions for pulling the safety card from time to time and rejecting a flight because of fatigue.

Management must do more. Often the safety training received at the administrative levels doesn’t filter down the line where it has the greatest potential for the good. Often a two tier system of safety is present and the information that needs to get to the folks in the aircraft trickles out of the corporate office. In this day of text messaging, e-mail and pagers, dissemination of information should be nearly instantaneous.

Flight Safety International has a motto of sorts: “The Best Safety Device In Any Aircraft Is a Well-Trained Pilot" I agree with that, but would go one further and say that the best safety device in any Air Ambulance Aircraft is a well trained and engaged crew. Always put safety above all else.