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Saturday, November 1, 2008

The Go/No Go Decision

One panel at the Search and Rescue Summit 2008 was “The Go/No Go Decision.” This interactive event revealed some pieces involved in deciding whether or not to scrub a mission. Risk management and communication were a common thread. “I think his point is communication within the aircraft. There are four guys in there that are going out to a really bad situation,” said Cdr Jim O’Keefe, chief, U.S. Coast Guard, “and all of them are thinking the same thing.” Following is an excerpt from the discussion. John Persinos, publisher, Aviation Today, moderated.

Persinos: Well, it's been a great day so far. The Helicopter Heroism Award ceremony was very powerful, as it always is.
    My name is John Persinos. I'm publisher and editorial director of Aviation Today. That's the online portal for our aviation products at Access Intelligence. I served for five years as editor-in-chief of Rotor & Wing, so I'm very familiar with helicopters and with search and rescue. I've met a lot of rescuers in the course of my journalistic career, and this was always the highlight of my stint as editor of the magazine - the annual Search and Rescue Conference, the Helicopter Heroism Award. Very powerful human stories. And we saw a lot of emotion today at the awards ceremony.
    This is a webinar - an interactive webinar. This is very much a participatory event. In the last 10 to 15 minutes, I'll be soliciting questions from the audience. So, as you listen to our panelists speak and as you see us go through the PowerPoint slides, keep a list of questions in your head. And then I'll call on each of you who raise your hand to come up to the mike there, and we'll get your questions, because I want you to interact with these experienced experts here.
    We are simultaneously online right now. People have registered for this webinar, and they're experiencing it online. And they'll be e-mailing me questions. And, occasionally, our administrators will hand me questions from our online audience. So this is a live webinar and an online webinar, simultaneously.
    And the topic will be making the go/no go decision. Risk management is very important in search and rescue. Sometimes the sense of mission, the passion for saving people in trouble can override sound aeronautical decisions - sound decisions as to whether you should fly. And sometimes crews put themselves in harm's way. And it doesn't do anybody any good if the rescuers and the crew perish. So we're going to discuss what sort of criteria need to be evaluated before a rescue crew can make a logical, rational decision whether they should go or not.
    On our panel is Capt Ardis Tang, Senior Pilot Government Flying Service, Hong Kong Special Administrative Region Government, and this is the organization that won the 2006 Rotor & Wing Helicopter Heroism Award; Capt Michael Chan, Controller Government Flying Service; Lt Col Steve Colby, U.S. Air Force, retired, Former Commander 34th Weapons School and a columnist for Rotor & Wing magazine; Cmdr Jim O'Keefe, Chief Aviation Platforms Division, Coast Guard Headquarters.
    And we have a last-minute guest but certainly a very worthy guest - Lt Cmd Eric Bader. He's currently the H-60 Engineering program manager at Coast Guard Headquarters, and he happened to be on his annual training in Mobile when the hurricane passed through last week. Lt Cmd Bader was on the rescue crew during Hurricane Ike that attempted to rescue a freighter that was trapped in gale-force winds, and they aborted the mission. You probably saw it on television. Twenty-two crewmembers were on the ship, and they made a decision that it was too dangerous to proceed. So he definitely has a lot of direct experience that's relevant to this webinar and a lot of fascinating anecdotes he can share with us.
    So we're going to go through the slides one by one, and we're going to get a good, lively discussion going here. These slides come from Capts Chan and Tang, and so I'll ask them to start the discussion.
    Let's start with Government Flying Service. They perform search and rescue, internal security, emergency medical service, firefighting, DIP. You know, sometimes it's a semantical issue. What is search and rescue? A lot of rescue outfits perform more than just rescue. There's an EMS component. There's a police component. Tell us a little bit more about your organization, which won the Helicopter Heroism Award in 2006.

Capt Chan: Well, we used the SuperPuma Mark 2 during the 2006 rescue operations. And we have flown three--altogether, one, two, three, four-- four missions to rescue altogether 91 survivors from the sea. And, well, during the four missions, we have made three go decisions, and we have made, actually one no-go decision on day one because of the changing situation and the external factors, as well as internal factors within the organization. And we found that, actually, the no-go decision is a more difficult decision than the go decision, because mostly people when they--especially front-line staff and front-line operators--when we face situations in which there are people--a huge number of people waiting to be rescued, we tend to be a little bit more emotional. We want to help them. And we must not let this emotion creep into our decision-making process. And we have to make--We have to stress to our staff and our front-line staff that we have to make some decisions based on professional judgment. And this is, I think, very important.

Persinos: Could our other panelists comment on that--the need to not be taken away by the emotion of the mission, the desire to be a hero, which can lead to some hot-dog flying that just puts everyone at risk? Could you flesh that out a little bit?

Lt Cmdr Bader: Yeah. I don't think the Coast Guard--I would hate to put us in the same sentence as hot-dog flying. But our guys do want to go out and perform the mission every time.
    We have a layered approach to how we look at operational risk management. Generally, we'll receive the mission through our command center, which would be either from a SAR (inaudible), a mayday, an overdo, a flare sighting or whatever. They'll take that information and decide whether or not it's a mission. They'll do an operational risk management assessment at that particular time.
    Then they'll pass it to the operational unit. There will be typically a duty officer that will take that call. Now, at this time, he's going to sign that. He'll call the crew--either wake them or get them from their desks--and bring them in to begin that discussion. He'll also call his operational--the operations officer. So we've got a lot of people that are involved in making this decision.
    The final decision always comes down to the pilot, and it's really up to him. And I think someone mentioned this earlier. I think the New York City guys were talking about it. If somebody says no, they're not given any crap about it. Our guys, the same thing, but they have a lot of help in that decision. One guy's got a lot of people to go to.

Persinos: Tell us a little bit about the ORM process, so to speak. I mean, I've seen that form that has to be filled out by the crew ahead of time. How much of it is sort of bureaucratic CYA?

Cmdr O’Keefe: I've actually had a lot of talks with some buddies of mine when I found out I was doing this and did some research. And the Coast Guard has an operational risk management instruction written by the commandant that covers, actually, all of our missions and not just helicopter. And it's a seven-step process. I know everybody else here has an ORM process. Ours is seven steps to identifying the mission, the hazards, the risks--I got this memorized. And we go through this process, and it's somewhat--you said bureaucratic; it seems that way. And if I'd queried by Coast Guard brethren out there, they'd go, What? It's 3500.3, by the way, is the instruction number. And they're probably going to go, I didn't know that existed.
    I'll go back to Pete Mingo, who was our earlier speaker. I know some of the people on the webinar didn't have the opportunity to hear him speak. But it comes back to our training. Our guys-- Believe it or not, you do your operational risk management every time. A typical day of a duty that you check in, you automatically check out your aircraft. You check out your goggles--your night-vision goggles. You get your equipment in order. You know your weather. So there's a--ORM is an ongoing process. Operational risk management is an ongoing process that we do every time.
    Now, as the mission becomes more complex, that spreads out and becomes more of a list-- of a checklist.

Persinos: Is it fair to say, though, that a rescue crew needs to keep in mind that it's a tool and not an end in itself?

Cmdr O’Keefe: Absolutely.

Persinos: Capts Chan and Tang, do you have anything comparable to an ORM procedure before you engage in a rescue mission?

Capt Chan: Well, I believe, like many other emergency response organizations or even, these days, commercial operators, we do have a model or system to assess the risk before we launch--before we decide go or no go. But we believe that this--At the beginning--At the initial stage or at the planning stage, this sort of decision making is on a static situation, because, before--Say, for instance, the rescue operations we conducted back in 2006--there was only so much information available when we were on the ground before we went. We knew that the typhoon was coming. We knew the position of the typhoon. We knew roughly from weather radar the severe weather around the general area. But we would not have a clear idea as to the actual situation before we actually arrived there.
    So, okay, we can do all these risk assessments and planning and crew briefing before going, but I think, at the end of the day, this is not only a go or no-go decision. This is probably when the crew actually arrives on the scene. This is a do or don't.

Persinos: I see. So what you're saying is sometimes risk assessment can be static before you launch the mission, but then conditions can change. So what's required is a realization that it's dynamic and that situational awareness is required. Correct?

Capt Chan: Yes. That's correct. In fact, that is an even more difficult decision to make. And this decision can only be made by the front-line people.

Persinos: Okay. Our next chart, Nature of SAR. Could you explain what you mean by nature of SAR?

Capt Tang: To describe the nature of search and rescue, we think there are some basic elements in it. Risk is inevitable. As a SAR unit and as an emergency response unit, you are prone to have risk in your missions. And that's why we think risk is inevitable.
    We think search and rescue is a risk management. That's why we're here today. And we talk about how to manage risk-- to minimize risk and, at the same time, to gain the experience, growth as a unit on that.
    Risk assessment depends on the experience and expertise. You need a quality decision made by the front-line crew and rely lots on their experience. And their experience also relies on the management style, the no-blame culture, as well as the organization's culture that creates an atmosphere that they can make and be confident to make their own decision. It may not be popular, but a hard decision.

Persinos: That's a fascinating point. Elaborate a little bit on the no-blame culture. What do you mean by that?

Capt Tang: No-blame culture is when you go out-- a front-line crew to go out to a difficult situation on scene assessment, with your experience and with your crew together, then you have to make decisions at that time. And it may not be the best decision, but that is the decision that you made together with your team. That requires a lot of support from your team and from your management that will help to create a culture for the unit in order to let other people--to make the same quality decision.

Persinos: Meaning that people will make better decisions if they know they won't get blamed after the fact-- that they won't be second guessing. They can trust their instincts better and make the tough decisions in the heat of the moment that they have to make.

Capt Tang: I think that's very, very important. Yeah.

Persinos: Okay.

Lt Col Colby: I'd like to piggyback on that, John.

Persinos: Sure. Please.

Lt Col Colby: One of the things that the Air Force culture is trying to do in terms of risk management is build a concept of sound judgment and decision making in our young pilots early. This form that you alluded to, it has become more of a bureaucratic paperwork tool. That's not what it's designed to do. What it's designed to do is to get the young guys, or the young folks, looking at critical key mission areas that they might overlook during a normal pre-mission planning process in the excitement of a mission tasking. And, by forcing them to go through the process, and iteratively go through it, it becomes, then, kind of a habit. And then, when a system comes up, it becomes your observe-orient-decide-act loop, if you will - your OODA loop - on how you're going to manage a mission.
    So what we force our pilots to do is evaluate these particular risks, whether they're mission enemy, terrain, troops time, and individual elements within those, like, for instance, the environment, degraded aircraft, objective. What's the recovery divert possibilities for aircraft performance? And it might be your wingman's performance. If you were a flight lead, you're going to be required to make a decision of who's going to go into the pickup area, perhaps based on who's got degraded engines or who doesn't.
    These are decision-making skills that we want to instill early. So we create a formalized process. That may seem bureaucratic, but there's a method to the madness. And that's the iterative muscle memory of your brain of going through (inaudible).

Persinos: Right. It becomes engrained behavior, which is important because most mishaps during a rescue are caused by human error. Correct?

Lt Col Colby: Correct.

Persinos: Mission, planning, execution, review. What are we looking at here?

Capt Tang: This is, in general, with an emergency mission, the sequence in chronological order - how things go on. When we got a mission on the ground, pre-launch phase, we can do the planning. And with the Coast Guard introduced the operational risk assessment model that covers very well on how to decide to go or no go on that side.
    But, after that, we go for the execution phase. When the front-line crew goes onto the situation with the quick assessment together with their crew, they make a lot of decisions over the execution side. And, today, we would like to spend and focus time a little bit on that.

Persinos: Okay.

Capt Tang: That is the more dynamic situation - time-critical, more dynamic analysis with the team with limited resources, comparing with the pre-launch decision.

Persinos: (Inaudible) based on how things are unfolding.

Capt Tang: Yes.

Persinos: Unseen risk assessment, something we were just talking about. Organization culture, SOP training, front-line--

Capt Tang: We think it should be from top down. It should be from the (inaudible) of organization culture and then down to your SOP. With the training and then you exercise in the front line. That is the way of exercising or promoting this kind of decision making in a unit.

Persinos: Typhoon Prapiroon, your rescue efforts during this disaster earned you the Helicopter Heroism Award in 2006. Case studies are really good because they teach tangible lessons from the real world. They go beyond just mere theory. And so we're going to discuss what the Hong Kong Flying Service went through during this typhoon and the lessons that can be gleaned from their experience - lessons that you can implement in your own daily operational lives.

Capt Chan: I'm sorry that this picture doesn't come up very well on the screen. On the computer screen, you should be able to see the coastline of south China and the South China Sea. The eye of the typhoon is the little, dark area to the left of the two red lines. And the two red lines are the two locations of the two incidents. Actually, we had two incidents - two separate incidents during that day. Actually, I put the month wrong. It's August 3 instead of September - August 2006.
    The typhoon was approaching towards the South China Sea. And, at that point, at around 11:00 in the morning, Cathay Pacific, which is a local airline, announced that they will stop all operations in the afternoon. So, soon after noontime, they stopped all the operations. And, around that time, we got calls from--two calls for rescues. There were, separately, two barges carrying people from the oilrigs in the South China Sea. They were actually doing--performing evacuation operations for the oilrigs. And one carried about 23, I think. The first one was carrying 23 survivors. And the second one was a huge barge carrying 68--not survivors at that stage. They were passengers at that stage.
    And the first one went aground. And they called for help because nobody was able to get close to the ship. And the second one--They were trying to reach the shore before the typhoon hit them, but they were not as quick as the typhoon. And, at some stage, they lost some power. And, when they tried to recover the engine, they lost it. They lost power completely. So they were now--There was total power loss in the middle of the ocean and watching the typhoon approaching.
    And we decided we'd get all the information, and we decided that early during the day, it was possible for us to depart IFR and then, when we reached the scene, find a suitable area to let down--to let down to the surface. And we did that. The first aircraft arrived at the ship, which was about 60 mi from Hong Kong. And it was having difficulty in letting down. Okay. Well, the go/no-go decision on the ground was, before we launch, was sort of easy, because we knew that we could depart safely. And we knew that we had all the alternates in our mind that we could go to if we could not reach the area safely because of various factors.
    But then, when the first aircraft arrived on scene, they started to face difficulty of finding a suitable area to let down. And they were circling around for like 10 minutes and, eventually, they found some suitable area to let down to surface. They went down to about 100 ft. They found the target. And, okay, it was a very difficult situation, but they managed to cope with it at that point.
    Now, the operating philosophy in Hong Kong--The way we operate, anyway, we never go out singleton. The helicopter always goes with a fixed wing. The fixed wing will cover the helicopter operations throughout the whole mission.

Persinos: Let me interject. How does that differ from your own operation of rules? Lt Colby?

Lt Col Colby: It's a two-ship--Doctrinally, it's two-ship for Air Force CSAR. Civil SAR may be a single ship. And, if you can have an overhead aircraft to help support, they will. But it's not doctrinally mandated.

Cmdr O’Keefe: The Coast Guard looks at different distances offshore. And, depending upon the airframe, whether it's a 65, which can go maybe five or six mi offshore or something like that--I think some of our (inaudible). Or, if it's a 60 that I fly, which is several hundred miles, you stay out there for-- If the (inaudible)'s in the room, maybe I need a job here pretty soon. [Just Kidding]
    It does depend on the airframe and then in distance off. And I'll probably get those wrong. But, if the weather--And then you look at the weather, and you bring that into your mission planning as to bring an overhead cover.

Persinos: Actually, let me interject. Sikorsky is definitely in the room, and I want to-- I'd be remiss if I didn't thank them for sponsoring this webinar. Sikorsky, Goodrich, and Argus have made this live and simultaneous online Webinar possible. So I want to thank them.

Lt Cmdr Bader: That doesn't necessarily mean you should give Cmdr O'Keefe a job, though.

Persinos: The revolving door is alive and well at the Sheraton Reston. We have a question from one of our online participants. This is the miracle of the internet. I'll need my glasses for this, though.
    Should the pilot know injuries and the situation of patient, or should we protect the crew? Who wants to tackle that one?
(technical difficulty)

Cmdr O’Keefe: -- situation of the patient. I can make the decision of whether I'm going to take him to Juneau, which might be farther away, or can I take him to Sitgo (ph), which is closer but not as-- The medical facilities aren't as good. So, from our point of view in the Coast Guard, I think that we need to know the entire situation.

Persinos: Let's move along to the next slide.

Capt Chan: Following on to where I stopped. During the rescue operations. At some point, because of weather static or terrain we don't know--We couldn't find out the reason--we lost communications with the helicopter--the first rescue helicopter--for 15 minutes. We could not call them up from the base. The airborne top cover--the fixed-wing top cover--We could not call them up from above. And, at some point, we thought that we lost it. But it was somehow--About 15 minutes later, they called up, and they told us that they were in the middle of rescue.
    Now that piece of information actually had some bearing on our subsequent operations on whether we should launch further aircraft or to wait until weather improvement.

Persinos: That begs a question. To what extent does a lack of communication, being incommunicado with other members of the team--? To what extent does that play a role in whether you decide to no go? How much of it is sort of a given during the dynamics of the situation. Eric, I'd like to hear from you.

Lt Cmdr Bader:    As Capt Chan was talking, there's a lot of similarities between the case that he's talking about and the case that we recently dealt with in Hurricane Ike. It was very similar to the same sort of relative position to the storm, very near the eye. It looks like you're about to describe a hoist from a really big container vessel or tanker vessel, from the look of it. Same sort of vessel. And we also had multiple assets out there. I was part of a two H-60 fleet that went out, and, actually, we made the decision to turn around. I can tell you that I've kind of been on both ends of this equation. I was fortunate enough to be part of a crew that won the Rotor & Wing Helicopter Heroism Award for hanging our crew out there a little further than I was comfortable with.

Cmdr O’Keefe: Way to work that into the conversation. That was nice.

Lt Cmdr Bader:    -- not the only one looking for a job, commander.

Cmdr O’Keefe:    Nothing wrong with a little self-promotion.

Lt Cmdr Bader:    It's well deserved. But I can say that, when I got back from that, I got second-guessed the other way. Wow, if you had done nothing, what do you think would have happened? It's hard. It's kind of like poker. You have to be able to--You don't have perfect knowledge ahead of time. If you did nothing, what would have happened?
    And, in our case, we did wind up turning around, and we had communication problems between our aircraft. And there were some Air Force aircraft that were coming out after us to attempt it in the event we couldn't do it. We had communication problems with them. And I think that's why it's important to push that decision-making authority down to a very low level within the organization. The aircraft commander, at a minimum, needs to be able to have that influence and not be second-guessed for it.
    I can tell you, in our case, I was considering turning around. The other pilot was considering turning around. Both the other pilots in the other aircraft that we were flying with were considering turning around. It was actually our flight mechanic who was the first guy that said, “Hey, sir, before we took off, you told me to speak up if I was feeling uncomfortable, and I just don't see any way that we're going to be able to do this. How about you guys?” That was the balloon that got released. All of us were, like, Yeah--

Persinos: It's important knowing that there's not going to be a stigma placed on someone if they raise their hand and say, Hey, this is too dangerous. We're not going to make it back. And it has to be a collaborative effort and a lot of communication, taking everyone's views into account. And it's not a top-down decision.

Lt Cmdr Bader: Exactly. I think it's got to--You've got to be able to empower everybody involved with the mission in order to say, Hey, I've at least got a concern, and we need to address it.

Persinos: There's sort of a consensus emerging here that there's all sorts of criteria and rules and lists and checklists. But, in the final analysis, making the no-go/go decision is more of an art than a science.

Cmdr O’Keefe: Absolutely. Eric makes a good point, which is unusual for him. He makes a good point about the communication. You were going for communication outside the aircraft - between aircraft, between the cover ship, between your home base.

Persinos: Right. That was my question.

Cmdr O’Keefe: Actually, I think his point is communication within the aircraft. There are four guys in there that are going out to a really bad situation, and all of them are thinking the same thing. But it took probably the most junior guy to say, “Oh, wait a second,” and to start the communication going. I think that's extremely important. It's more of a CRM, crew resource management, issue, but it does apply.

Persinos: Right.

Capt Chan: Again, back to where I stopped earlier. Following the breakdown in communications for 15 minutes, we decided instead of launching the second aircraft immediately to tend to another ship, we decided to wait until the first aircraft came back. And then we used that period to reassess the situation. Why did we lose communication? Is it because of equipment problem? Is it a static problem or whatever? So we gave ourselves some breathing space to reassess the situation.
    Now, that go/no-go decision was done on the ground. Again, because of all the information there already, we feel that that decision, at the end, was not that difficult, because it was sort of static, not dynamic.
    Then, when the second aircraft came back, we have--we figured out that it could be because of the weather. It could be because of the terrain we lost communication for 15 minutes. But everything was fine. Everything was fine, and we still had another set of fresh crew. We still had another fully serviceable aircraft. So we decided--On the ground, we decided to dispatch the second aircraft.

Persinos: I have a question here, and this is the right time to ask it, from one of our online registrants - someone who's participating and is webinar viewing it on their computer. They ask: What were the seas and winds during the Prapiroon mission? What were the seas and winds? What kind of weather conditions did you face?

Capt  Chan: Well, the sea state was-- rough estimate was about 60-ft wave.

Capt Chan: Violently though. Well, the wind--When I first looked at the air speed indicator, it was something like 72, but it was not steady, as you could imagine.

Capt Tang: A lot of gusts.

Capt Chan: Somewhere close to the eye of the typhoon. It went down a little bit for a while, and then it went up to 80. It was sort of fluctuating, obviously, between 60 and 80 all the time.

Persinos: Wow. Pretty intense. Next slide - On Scene Risk Assessment.

Capt Tang: Yes. This is a model that we would like to introduce. It's slightly, for most of the experts who are here, slightly simplified version of how to do a risk assessment on the sea. We won't be able to bring along the matrix and difficult matrix to do it in the air. And I think that would be a good way of memorize how to do the risk assessment. I hope with this introduction of this model that will help us to do more comprehensive considerations of making quality decisions.
    To look at it, it's a triangle with three angles. On the top one is the crew. On the left is mission, and on the right is environment. And, in the middle, it's risk. Basically, the outside triangle, the outline of the triangle, is dynamic. If we got the crew-- If we consider the crew, including the CRMs, including team spirit, including team physical or mental ability--If you have a low index on the crew, then you will be close in to touch the risk triangle in the middle.

Persinos: Okay. Let me ask the other speakers, because I obviously want to get their participation. This triangle that Hong Kong flying service uses, how applicable is it to your own operational realities - to your own organizations? Is it relevant? Do you use something similar?

Cmdr O’Keefe: From the Coast Guard, no, not really. I don't see Commander Mingo here, but--

Cmdr Mingo: Oh, I'm here.

Cmdr O’Keefe: Oh, you are. Excellent. Yeah, you gave my lecture earlier, by the way. Thanks. I appreciate that.

Persinos: He's been seriously taking notes.

Cmdr O’Keefe: He is. But he's from Aviation Training Center Mobile. Pete mentioned it earlier what we provide to our organization. It's not as visual as that. It's more of a "put our guys into different situations in simulator." He mentioned our simulator, and I know a lot of folks out here do have access to that. In our simulations, we put the guys through incredible situations and try to see where they're going to go and whether they're going to go. It's a great tool, I think, we can use to put them in--give them the opportunity to make decisions without actually having to face the real risk.

Persinos: Okay. Another question from one of our online registrants. This person asks: Obviously, the pilot has ultimate authority. Does the pilot have authority to say where they may take patients with respect to their situation? It sounds like a question from an EMS operator. Who wants to tackle that one?

Capt Chan: We do quite a number of EMS transfers, the medevac, on a daily basis. Now, because of the special geography in Hong Kong and Hong Kong being a very small place, we will leave this decision to the doctor. Normally, the patients or the survivors or the injured person, they don't call us up directly. They would do that through a hospital or through a doctor. The doctor will make initial assessment as to where should the patient or the injured person go and will act in accordance with their judgment.
    Now, on certain days in the week, we have doctors and nurses coming to the Government Flying Service. And they provide air medical service--voluntary air medical service. Now, if we have them on board, then we'll defer the decision to them.

Persinos: Okay. Got you. Let's move along. We have several more slides to cover.

Capt Tang: Talking about the crew, there are--It's actually the topic of crew. So we go on with the next slide, please--Including the Team. Next please. The mental situations of the crew - how mentally prepared they are, how physically prepared they are, and, also, how much experience they have.
    And to talk about communication within the crew, we just talk about within the aircraft during the mission. As a commander, you really need to encourage people to speak up. Otherwise, people would-- may keep quiet. And you really have to encourage them to speak up in order to get a good grasp of how people-- how good-- how well prepared they are in order to help you make the decision of continue to do it or not.

Persinos: Ardis, I just have a quick question for you, just so everybody's on the same sheet of music. The way I read your chart is the outer black trace represents almost a limitation. In other words, it's either a crew limitation or a mission limitation or an environment limitation. And the size of that can change. For instance, crews' capabilities can decrease if you have decreased mental or physical capability, and that would actually bring that trace in closer.

Capt Tang: Yes.

Persinos: But the inner triangle can also change in size. In other words risk can increase and approach that, even though that crew might be perfectly capable. Am I reading this chart right?

Capt Tang: I totally agree. Yes. And to talk about environment, there are factors they’re, including aircraft itself, the weather, and also the fuel endurance and escape routes or Plan B, the trend. At the moment, it may be good. But you have to anticipate what's going on in the next hour or next half an hour when you need to complete the mission.
    And then the third angle is the mission. The next slide, please. The mission is about-- There are three factors. Next slide, please.
    The gain we always weigh between the gain and the risk and the benefits to the unit, the benefit to the crew, and how many-- basically, how valuable is your mission? And then how immediate action is required-- how immediate your action is required. Can you wait if it too high, the risk? Can you really wait?

Persinos: Related to that, is immediate action required? I remember in 1998, the winners of the Helicopter Heroism Award of Rotor & Wing was Queensland Rescue in Australia. They conduct a lot of heroic rescues out there, for obvious reasons. And the captain of the team--His name is Peter Hope--He touched on this issue. He said it takes a lot of emotional self control for a pilot to say no when you're told that, if you don't go out, those people are going to die. If you don't go out, they're going to perish.
    And I hate to add this footnote, but a couple of years later, Peter Hope did die in a rescue, sad to say. He was a great guy. But how do you overcome that sort of--? He talked about the need to steel yourself against emotional blackmail. Could you talk about that a little bit?

Cmdr O’Keefe: Again, from the Coast Guard's perspective, I can tell you we've lost crews. And we lost one recently; we mentioned that earlier. That was a training incident. But, in the ones we've lost for SAR-- I've got a lot of Coast Guard friends out there that probably can get me on this, but there's many times when we've lost our crews for SAR that the next morning the boat comes sailing in. So you can be given that emotional blackmail by whoever's delivering it, but that doesn't-- It happens. It absolutely happens. But we have very professional crews and, really, below me--much below my level. The guys out there, the aircraft commanders--The crew that won, they're sitting right out there. They won this year. They're not going to accept that. They're going to make professional decisions. These are great folks that have been well trained. And, hopefully, our commanders, people my level and above, won't do that. And that's something that hopefully will come from our culture that we're not going to allow that.

Persinos: I talked to a rescuer once. He said it sometimes galls him that he has to interfere with natural selection. Some people deserve to win the annual Darwin award because they insanely put themselves in harm's way. Did you coin that, Lt Col?

Lt Col Colby: Yeah, I did.

Persinos: That sounds like you.

Lt Col Colby: That's been in my e-mail signature block for years. We're fighting the biggest battle in aerial warfare, the battle against natural selection. That's just the name of the SAR business.

Capt Chan: One of the questions we received earlier touched on this topic--whether the pilot or the crew should be kept aware of the severity of those people who are waiting to be rescued. There are two schools of thought. And I believe, some time ago, there was one school of thought, at least in the UK, prevailing that the crew should not be given any detailed information on the situation. They should be-- The crew should treat that as an operational flight, and they should make a decision based on purely professional judgment. We have a slightly different view on that in the GFS, in the Government Flying Service. We think that we should weigh the risk element against what we can achieve. Like you said, if you don't go out, these people will perish. Okay, well, we know that, and we can probably--With that in mind, we can probably accept a higher level of risk. However, we may be able--Because of the severity of the situation, we may be able to give more protection to the crew and to the aircraft before going. Like--

Persinos: I was going to say, it's a good idea to keep the mission generic and not let the crew too many particulars. For instance, if a pilot is informed that there's a 10-year-old girl who's bleeding to death or something, he may have a daughter, and it may cause him to push the envelope in terms of risk. Is that what you're talking about?

Capt Chan: No. I think to enable the pilot to make professional judgment and professional decisions, it comes to the--This is really management's responsibility. The management has the responsibility to foster a no-blame culture in the unit and the department. And the management has the responsibility to provide the proper training--the training required to enable the crew to make such professional judgment and professional decisions and not to be affected by emotion or politics.

Persinos: You know, these are some subtle cultural and attitudinal issues we're talking about and not as cut and dried as flying skills and flying training. How is this inculcated as a seamless part of the training? Steve?

Lt Col Colby: I can talk to that. You bet. One of the things that I like to see go on in training is, as folks develop their skills, they get to the point where they're making decisions on the fly. And, as they make those decisions, you come up with some criteria. You say, if we see anything worse than this--in other words, you establish your crew a minimum visibility. And, as you're heading out there, you query the crew. “Okay, crew, what do you--?” “Right scanner, what do you think your visibility is?” “Well, sir, I've got a quarter of a mile.” “Okay, copilot, what do you see?” “Oh, man, I've got about three-eighths of a mile.” If you've established or pre-coordinated ahead of time--Hey, if we hit one-quarter mile, that's it.
    I've seen crews establish three things. If these three things happen, we're done. We're coming home because we've gotten to the point now where the mission has deteriorated. And that takes a little bit of the subjective nature that--Ardis, you were talking about it. That makes it a little bit more objective, and it gives the crew a sense of ownership as a team. Hey, we're sticking to our guns, and we're not going to go out there and attempt to join the shallow end of the gene pool with the guys that shouldn't have been there.

Lt Cmdr Bader:    I think with the--I'll mention that the case we turned around on--those 22 guys weathered the storm on that 600-ft freighter just fine. Like, they're in port right now. That's a hard thing to--I've seen a lot of different ways to try to quantify risk, but the other half of the equation is risk versus gain. It's really hard to figure that out, unless you have perfect information about--Is the 10-year-old bleeding? How fast is she bleeding? I'm not a doctor. I don't know--That's the really hard part of the equation. I've seen a lot of different--We have a metric to figure out what our risk is, but not all risk is generic. You're willing to risk a little more to save six lives to go completely on a training event. In my opinion, that's the really, really hard thing to do, and you can't do that without a lot of experience and judgment, I don't think.

Persinos: Our last bulleted item here - Number of Survivors.

Capt Tang: Yes. We think that puts a weight on the mission considerations as well. And this is a demonstration of the situation in the Typhoon Prapiroon when Capt Chan went out in the last-- n his mission. The environment is very bad. The typhoon--near the eye of the typhoon, and the situation was bad. And the crew themselves are getting--At the end of the mission, they are getting very tired. They have to pick up how many sailors on board together?

Capt Chan: It was--Altogether; we managed to pick up 28.

Capt Tang: Yes, 28 survivors in high-seas state. You have to hold quite a long time--almost an hour or more than an hour in high-wind situations. You have to hover and concentrate for that long. I think that reduced the crew index furthermore, and that brings that outside triangle closer to the inner triangle--what we think is very close to the high-risk level.

Persinos: We're going to reserve the last five to ten minutes of the session from questions from the audience. But does anyone have a question they'd like to pose right now while it's fresh in their mind related to the discussion right now?

Unidentified Participant:    Yeah. I would like to.

Persinos: Please, go ahead. Identify yourself, please, at the mike.

Carlos Gonzalez:    Carlos Gonzalez. I'm the SAR Advisor for the Department of State in Bogotá, Colombia. I'm also a reservist with the 301st Rescue Squadron at Patrick. Colonel, how are you doing?

 Lt Col Colby: Good.

Carlos Gonzalez:    For Capt Chan, my question for you is I would like to know: What is the level of training that your crewmen in the back are flying? Are they flight engineer? Are they crew chief--the one that operates the hoist?

Capt Chan: They are--Well, they are very close to your crew chief in the American system. But we have adopted the British system. They are what we call crewmen. So they are typically trained on basic navigation and operations of helicopter, and they work hand in hand with the pilot. They give--They are-- Well, when we go into some confined areas or when we go close to obstacles, they will be acting as an additional pair of eyes, and they will give patters to the pilot to position the aircraft safely. Because of different system, it's very difficult to compare to your crew. But, well, essentially, they are like your crew chief.

Persinos: (Inaudible) slides to cover. The Sichuan Earthquake is another great case study.

Capt Tang: Yes. On May 12, 2008, we have Richter scale 8.0 of the earthquake, affecting the Sichuan Provence. In this mountainous area, there are--With this sudden earthquake, all the road is closed, all the water is contaminated, food and medicals and communications is break down. A lot of people trapped inside valley. That's why helicopter at that time is crucial and very important. And the Minister of China called upon any helicopter that can help. So, at that time, 30 civilian helicopters were called upon, together with, altogether, 70 military helicopter to work together to do the rescue.
    This is a good slide of how mountainous--In the mountains, this is a typical weather change. We were orbiting around this valley and trying to go into this valley to execute a rescue, but you can see the in the slide on the left-hand side and the right-hand side. We got the buildup of the clouds very, very quickly.

Persinos: That was a scale 8.0 Richter.

Capt Tang: Yeah.

Persinos: And how high does the Richter scale go?

Capt Tang: I don't know.

Unidentified Participant:    It's a lot of rhythmic.

Persinos: It was a massive, massive earthquake. Continue.

Capt Tang: As you can see, we were doing mainly the evacuation job in this earthquake. And the patients--The survivors are--We have to make use of the whole cabin. We cannot really have the resources to put them on stretchers and transport them. We worked together to the People Liberation Army of China and executed the rescue. You can see the sheer scales of those rocks and the landslides and the devastating situation after the earthquake was so dramatic.
    And, from time to time, we have a lot of missions, and-- because of the long mission, we send a team to go up together with one aircraft. We spend two weeks with insufficient rest and repeating in high-risk rescue evacuations. We think, at the end of the day, we found the risk and environment as factors and the crew factor is building up the risk a lot.
    This is the first mission that we went for. To start with, we were doing the logistic flight, and when we arrived at the location. There are 30 survivors--in a mine site with 30 survivors we need to rescue. But at that time, on the first one, we cannot do that, because we're too heavy. Altogether--I don't know how many bottles of water in the aircraft, and we are not ready with the crew. So we went back and then reassessed the situation--take the less few for better performance, and then we go again. And then we think, on the second flight, we have-- we can contain the risk better, so that's why we go for that one.
    And, day by day missions--The main consideration was the environment that--The steep valley, the high-altitude flying, the obstacles, wires, and the FOD, affecting us--That's giving us the main consideration, the environment.
    And then approaching after two weeks gone by, I think our crew has been repeating exposing themselves in this high-risk environment. They seem to accept it as a norm. And I think this complacency is getting dangerous as well. I think in the CRM point of view, this is no good. As a commander, you've got to be sensitive to those risks as well. It's very subtle. And, at the end of the day, at the end of the missions, we rescued 96 people from the mountainous area in 26 missions.

Persinos: Amazing. All right. We're going to end the webinar right there. However, the formal webinar is going to end, but the speakers are going to stick around to answer your questions. So we'll go five or ten extra minutes because we do want to get your questions. But our online audience is off. However, I've got a backlog of questions from our online folks.
    One is: Does anyone have any experience with training such as the global war on error that interactively deals with human error dimension of risk? Lt Col Colby, the global war on error?

Lt Col Colby: That's that shallow end of the gene pool that I was alluding to. The Air Force has a program called verification training that they'll do, for instance, prior to a combat deployment. And the whole concept of verification training is designed, as you described, in like a simulator environment. It's to put somebody in the situation, allow them in a relatively, real world, low-threat to make decisions as they would in combat. And they take those decisions and then afterwards, in a hot wash, they just rip them apart. Okay, this is where your decision-making process broke down. And, hopefully, when you address those errors in decision making early, once again, you're beating home that muscle memory for how to make these decisions early in a non-threatening environment. So when it happens to you in the real world, it becomes almost an instinctual decision-making process. And I think that's how we address the global war on error.

Cmdr O’Keefe:    One thing that we've also--just to add onto that--is something called error management. We all make mistakes. We're all human beings. That's one of the beautiful parts about being a part of a helicopter crew. It's not when you make the mistakes; we expect those. It's how you react to them. And that's part of our training that we emphasize is don't get on someone for making a mistake; help them correct it.

Persinos: Okay. I got another question here. USAF Commander (inaudible), and this is a paraphrase: If the aircraft commander turns down a mission that can't be taken by another aircraft commander unless conditions change, do similar policies exist for any of you?

Unidentified Participant:    I don't know if that's written anywhere. I've always heard that anecdotally that, if you're on duty, they're not going to call--and if you turn something down, they're not going to call somebody else in to do it. But people that are smart are shaking their head. That is written down, it turns out. Good to know. I'm going to open that book up right when I get back to the office.

Unidentified Participant:    I'll get into the details of specific missions, I actually have seen that exact error made, where a mission was turned down by somebody who had just been in a region where the weather was absolutely garbage and somebody who wasn't collocated where the weather was so bad actually flew from a great distance and then got in trouble there. And that was just a travesty.

Persinos: Okay. I'd love to get some questions from the audience. Sir, if you could identify yourself at the microphone?

Cmdr Mingo: Cmdr Mingo from U.S. Coast Guard. What I'd like to add to that is that the Coast Guard typically--We don't turn over missions like that, unless there's an appreciable change. One of the situations that may occur is the easiest one. You have an oncoming crew at 8:00 in the morning. When that crew comes on and they're fully rested, that's an appreciable change in the crew complement, and that's what can dictate a commanding officer to make that decision that that crew can in fact go perform this mission if the previous crew has been up all night trying to prosecute it. So just understand that there's a cut and dry--You can't just take one crew and transplant them into another position. There has to be something about them. And maybe it's a qualification that one of the pilots doesn't have. Maybe the crew mix isn't right. But, generically speaking, we don't do that. We don't just presuppose that someone else is more qualified. An aircraft commander is an aircraft commander, and so on and so on.

Persinos: Great point. Thank you. Thank you very much. Other questions? Surely you must have some questions for our speaker panelists. Sir?

Mike Paulaitis: Mike Paulaitis with Sikorsky. I had a question dealing with their risk triangle. They had aircraft and environment. Being a ghost of Coast Guard aviation past, we had a helicopter that only did 90 kt. So we used to do unique things to enhance its performance, like get rid of non-essential equipment like the copilot's seat, the HF radio, (inaudible). And I'm quoting actual missions there.
    But I was just wondering: How much do you look at bumping or improving the performance curves of the aircraft you're flying? When you go out and do your morning performance check on the engines and you're low but within margin, how do you feel? What do you look at those issues?

Cmdr O’Keefe: Well, there are certain things--Again, speaking for the Coast Guard, normally you go out and fly with an aircraft that's perfectly fine. Let's say it doesn't have a radar. Well, in the Alaska environment--Most of our environments that we work in, that's almost a down aircraft. So there are certain pieces of equipment and pieces of gear, depending upon the mission that I'm just not going to take off without. Degraded engines--He's an engineer; he fixes my airplanes for me. And he does a fine job, as do all the folks that work for him and as does Sikorsky, by the way.
    But mission equipment and stuff that might not be available to me will affect my decision on whether or not I'm going to take that aircraft. Correct.

Cmdr O’Keefe: This happens routinely in errors where aircraft in particular areas, like Afghanistan where their aircraft are on the hairy edge of their performance envelope. For instance, you could make an analysis to say, “Okay, we're pretty sure that the radar threat here is pretty minimal, so do we really need to have things like radar warning installed?” We know that there's not going to be a lot of electronic environment going on, so do we need to carry a multi-mission advanced tactical terminal, a 53-pound boat anchor in our tailbone? No. We don't need to carry those things. Those are conscious decisions that are made and removed.
    It's a great question that you led up to with the performance of the motors. That's another one of those criteria that we'll usually establish as being tighter than what the regulations require when we're back stateside. So what would normally be a 0.90 motor on a Hawk, when we go to Afghanistan, we'll say, “Okay, 0.95 is our limit before we're going to bust out the engine wash kit. And, oh, by the way, we're not just going to wash the compressor; we're going to wash the hot section too.” Stuff like that. We make those kind of calls.

Persinos: That was a great question. Any other questions? Please identify yourself.

Dave Downey: Dave Downey, the vice president of Flight Safety at Bell. Just a comment. There's a thing called weatherturndown.com, which I'm not sure everybody's aware of. But it's a service that is absolutely free. You go to it, you sign up, and what it does is, if an EMS operator turns down a mission in a particular area, those that are subscribing to it, basically, why they turned the mission down and what the time was and where they were. And what this does is that allows the sharing of useful information so that, as we know in the business, hospitals will shop for an operator to come pick up a patient to transport them. They're going, Well, if you won't do it, this person will. And what that does is that basically puts out onto the net the fact that this has been brought up. And what we liked about it in my previous world in the FAA was the fact that you're now on notice of the fact that this mission has been turned down. So, back to the gene pool issue, what that does is that helps vaccinate some of those stupid people.

Randy Jones: John, this is Randy Jones, publisher of Rotor & Wing. One of our guests here at the show also suggested that we use the search and rescue Web site that we've created as part of this as a clearing house of best practices, which is--There may be other places; we don't need to recreate the wheel. But, if there isn't, we're open to that and open ideas and offering the way to have you guys-- give you guys a forum for that.

Lt Col Colby: Call it the doofer book. The doofer book. In the Air Force culture, literally, in the squadron we have what's called a doofer book. When somebody screws something up, it goes in the doofer book with a funny, humorous, anecdotal story that goes along with the lesson learned. And you can do it as pretty much non-attribution as you want. But then the story's always there.

Cmdr O’Keefe: We have the same thing. I just can't give you the name of it.

Persinos: This is a family webinar. But we have a social community networking aspect of Aviation Today called the Aviation Professionals Network, and I'd urge all of you aviation professionals to sign on. You can swap stories and anecdotes and your impressions of this conference and exchange information.

Unidentified Participant:    The Coast Guard is welcome as well.

Persinos:    Even the Coast Guard.

Unidentified Participant:    Even though it's professional (inaudible).

Persinos: Especially the Coast Guard is welcome. Any more questions? Any more questions? We've got a rare assembly of really experienced rescue experts here. Now's your chance to ask them some questions and take advantage of their knowledge.
    All right. Well, we covered a lot of territory in an hour--a lot of territory. I want to thank everybody. I especially want to thank our speakers for taking time out from their busy schedules to be here.
    Fill out your-- Please, if you could do us a favor and fill out your evaluation forms and let us know what you think of our-- what you thought of our live, simultaneous live/online webinar. Thanks for joining us. Thanks for being here. I'm John Persinos, and come to www.aviationtoday.com. And I hope to speak with all of you after the conference. Thank you.

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