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Wednesday, February 1, 2012

Own Worst Enemy

By Andrew Parker, Editor-in-Chief

As we head into Heli-Expo, it’s important to again bring up the subjects of training and safety. Learning lessons from the mistakes of others is one of the most basic ways of improving.

The U.S. National Transportation Safety Board issued similar rulings on January 19 involving two helicopter EMS crashes where pilots flew into storms at night. The first crash, which occurred Sept. 25, 2009 near Georgetown, S.C., involved a Carolina Life Care Eurocopter AS350B2 operated by Omniflight Helicopters. Three people died in the crash, the pilot, a flight nurse and a flight paramedic.

According to the report, the pilot decided “to continue the VFR flight into an area of IMC, which resulted in the pilot’s spatial disorientation and a loss of control of the helicopter.”

NTSB noted “inadequate oversight of the flight by Omniflight’s Operational Control Center” as a contributing factor to the accident, which happened at around 11:30 p.m. as the crew was headed back from dropping off a patient.

The second accident took place on March 25, 2011 near Brownsville, Tenn. The Hospital Wing Eurocopter AS350B3, registered to Memphis Medical Air Center, went down after heading straight into a quick-developing weather cell, resulting in the deaths of the pilot and two flight nurses. The safety board ruled that attempting to fly into “adverse weather, resulting in an encounter with a thunderstorm with localized IMC, heavy rain and severe turbulence,” is the probable cause of the crash.

What’s disturbing is the part of the report’s narrative that describes the pilot’s apparent state of mind before the crash. In a conversation with an oncoming shift pilot, the pilot allegedly said he “wanted to get the helicopter out” after sitting on the helipad at Jackson-Madison County General Hospital and waiting for the flight nurses. The shift pilot suggested parking the helicopter, but the active duty pilot insisted there was enough time to make it, believing “he had about 18 minutes to beat the storm and return to home base” while leaving the nurses behind. The shift pilot later spoke with one of the flight nurses, who in fact made it on board and said they were about 30 seconds from arrival, when the helicopter went down.

Witnesses reported lighting, thunder and “heavy rain bands” in the area at the time of the accident.

NTSB faults the decision-making process of the pilot, saying that he “could have chosen to stay at the hospital helipad. The pilot, however, decided to enter the area of weather, despite the availability of a safer option. Based on the pilot’s statement to the oncoming pilot about the need to ‘beat the storm’ and his intention to... bring the helicopter back, he was aware of the storm and chose to fly into it.”

The report continues by stating the pilot “made a risky decision to attempt to outrun a storm in night conditions, which would enable him to return the helicopter to its home base and end his shift there, rather than choosing a safer alternative of parking the helicopter in a secure area and exploring alternate transportation arrangements or waiting for the storm to pass and returning to base after sunrise when conditions improved.”

NTSB also noted that the pilot “was nearing the end of his 12-hour shift, during which he had flown previous missions and may have had limited opportunities to rest. He had been on duty overnight, and the accident occurred at an early hour that can be associated with degraded alertness.”

Sometimes, we are our own worst enemy. Human error, whether it’s caused by fatigue, the desire to finish a shift, or any of a large number of other casual factors, is a part of aviation operations. The stakes for aircraft operators are high, we all know that, but it’s important to keep this in mind as an example of where the decision to push forward into the gray area can have dire consequences. When dealing with Mother Nature, know your limits. The line may be closer than you think, and at times we can all be one bad decision away from disaster.

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