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Sunday, October 1, 2006

Safety Watch: Unhealthy Competition

Tim McAdams

According to the NT SB, on the night of Jan. 10, 2003 at about 19:54 local, an air medical helicopter was dispatched from Salt Lake City to Wendover, Utah (just over 100 mi to the west).

After departure, the pilot contacted the Salt Lake City (SLC) air traffic control tower and requested an I-80 transition low-level westbound to Wendover. The tower instructed the pilot to hold east of SLC due to landing traffic. The pilot held at 700 ft agl for about 19 min while monitoring the tower and the ATIS frequencies. The pilot stated the weather drastically changed from 2 mi visibility to 1/16 mi in fog. Due to the deteriorating weather, the pilot elected to abort the flight and return to the hospital. After completing the shutdown and postflight procedures, the pilot returned to the dispatch facility. As the pilot entered, he heard dispatch personnel and his crew discussing that another air medical service was attempting the flight. The pilot then contacted the other pilot on the radio and reported that he just aborted the same mission because the visibility had reduced to 1/16 mi. The other pilot stated he was going to try to get over the fog.

At 20:31, the other pilot contacted SLC tower for a departure clearance from the hospital. He was cleared to proceed toward SLC via the signatory letter of agreement (LOA) and enter the Class B airspace. At 20:33, the pilot advised the tower that he was attempting to climb out of it and requested clearance to 7,000 or 8,000 ft. He was cleared for the ascent and to remain east of SLC. At 20:35, the tower inquired how high the pilot wanted to fly to obtain VFR. The pilot reported that he attempted to climb; however, he would lose VFR and requested not to do that, but to transition through the SLC airspace "to see if it clears up any better for us." The tower advised the pilot the visibility was 1/16 mi and to proceed inbound via the LOA and remain east of SLC. At 20:37, the tower asked the pilot if he could continue westbound and the pilot responded, "I'd like to give it a try if I could."

At 20:39, the flight was cleared westbound and to maintain VFR at or below 5,000 ft. At 20:41, the pilot stated he was on the west side of the airfield, and requested to return back to the east. At 20:44, the pilot asked the tower whether he was cleared back to the east. The controller informed the pilot that she could not let him go east until he could see other aircraft on final approach to runway 34R or she had a break in traffic large enough to get him back to the east side.

While holding, the pilot had the following conversation with his dispatch center:

"We are on the west side of the airport," the pilot said. "Air Med got sent out for this same damn thing and then they called us to go out. Air Med turned around for low visibility, so they go shopping for another helicopter and we're turning around at the west side airport. You know, it what's their determination, you know."

"I understand," the dispatcher said. "Unfortunately, that happens all day long. A lot of the dispatch centers do it, but, so I understand that you are turning back twenty." "I mean, they need help," the pilot replied.

"I mean, when they need help, it's not, you know, like they call to just hi themselves anyway, there's a ton of air traffic out here, so we'll wait to cross back over the airport. At 20:50, the pilot told the tower, "I'm basically inadvertent IMC at this time and declaring an emergency." Twelve seconds later, the tower asked the pilot whether he had Runway 34L in sight.

"That's negative and I'm currently on a heading one five zero,"  the pilot responded.

The tower instructed the pilot to turn right to a heading of 340 deg for a vector toward SLC. The pilot did not acknowledge the instruction, and the tower controller again attempted to contact him. No further communications were received. The Salt Lake City Police Dept. received a 911 call from a witness at 20:56, reporting, "very thick fog...the helicopter barely missed their trailers...fog is very thick can only see 40 ft ahead." At about 21:40, police officers and the witness located the helicopter wreckage.

The Agusta A109K2 twin-engine helicopter was destroyed when it impacted terrain while attempting to maneuver in dense fog. The instrumentrated commercial pilot and the flight paramedic were fatally injured, and the flight nurse was seriously injured.

The NTSB determined a contributing factor was the pressure to complete the mission induced by the pilot in command as a result of the air ambulance operation.

Shopping for an EMS helicopter is all too common in the air medical industry. Pilots should always be told if another service has turned the flight down for weather. Accepting a flight that has previously been turned down or aborted for weather should only be done in special cases, such as by an IFR-capable program or during highly isolated weather conditions. It’s difficult for a dispatcher to know when it’s appropriate to ask another service, so ultimately it is the pilots that must understand when to say no.


Tim McAdams has more than 9,000 total flight hours, with 7,000 in helicopters. A helicopter CFI and a fixed- and rotor-wing ATP, he flies a single-pilot IFR Agusta 109E for CareFlite in Dallas. You can reach him at rotorandwing@accessintel.com.

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