Due diligence

September 28, 2009 by Tim McAdams

In response to my previous blog, Jon S. brought up some very good points. He questioned whether an EMS pilot would climb into the clouds, autopilot or not, if he or she would face an FAA violation for doing so. He is absolutely right as declaring an emergency does not guarantee a pilot won’t be cited with a violation. The FAA has taken the position that if the emergency is caused by the pilot’s action or inaction, then a violation is appropriate. In many cases the NTSB has upheld the FAA’s decision.

 

So how does this affect an EMS pilot’s decision making process? Well, in all the EMS Part 135 operations manuals I’ve read there is a defined procedure for inadvertent IMC. Basically, it is to climb, contact the nearest ATC, declare an emergency, and perform an instrument approach. In discussing this with other operators, I was told that the local FSDO has taken the position that if a pilot does the appropriate due diligence that they will not pursue a violation.

 

According to the NTSB, on June 8, 2008, an EMS pilot in Texas aborted a flight because of low clouds and fog encountered en route. The request was then made to a different operator. The second pilot was notified of the flight and performed a weather check for the route of flight. After his weather check, he contacted his company’s Enhanced Operational Control Center (EOCC) to discuss his weather observations and the previous turn down. Both the pilot and EOCC supervisor were observing 10 miles visibility and ceilings acceptable for the flight. At that time, the pilot or the supervisor did not understand the reason the other pilot turned down the flight. The pilot contacted EOCC a second time to discuss that the previous flight had been turned down because of fog. The pilot and the EOCC supervisor again discussed weather observations with the same conclusion, that the restriction to visibility reported by the previous flight was not observed by any official weather reporting station.

 

The Bell 407 crashed in densely forested terrain killing the pilot, flight nurse, and paramedic. Sheared treetops indicated initial impact occurred with the helicopter’s main rotor blade system in a straight nose-low attitude. It happened in the exact location where the other EMS pilot had encountered low clouds and lost reference to surface lights. The other pilot told the NTSB there were no traffic or weather concerns at the time of his departure. While en route, approximately five miles south of the hospital, at 1,400 feet he encountered wispy clouds. He descended to 1,200 feet and encountered more clouds, continued to descend to 1,000 feet and encountered even more clouds, and finally descended to 800 feet when the visibility decreased rapidly. He stated that he could see to the east but had lost his surface light reference. He turned immediately to the right, towards the freeway system, and was back in good weather. He stated that the low clouds and visibility were very sudden and dramatic.

 

Whether a potential FAA violation affected the accident pilot’s decisions that night will never be known. This kind of accident happens too often in EMS operations as some pilots obviously underestimate the potential for a CFIT accident. Better training would definitely help. I think climbing is normally the best option, however, Jon’s point is well taken and EMS pilots who could be put in an inadvertent IMC situation need to be sure they perform reasonable due diligence.

 

Another good question is whether all EMS operations should be flown under IFR. That’s coming up next.

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20 Responses to “Due diligence”

  1. Avi Weiss Says:

    Tim;

    Not sure if you saw my comment on previous post related to having different classifications of operations and matching aircraft requirements and crew training to those classifications.

    Given the inherent benefit of having the most amount of mission flexibility allowed for an EMS mission, but still providing some modicum of differentiation between the vastly different mission profiles possible in EMS, having some sort of “graduated” classification system akin to type and pilot rating I think would at least provide SOME baseline of structure, without unduly restricting EMS operators from performing lifesaving missions, which a “one-size fits all” approach of IFR-only would severely limit.

  2. nate_fl Says:

    Tim, thank you for the thoughtful discussions of this issue. I’m not a helicopter pilot, but these “mission fixation” discussions are useful to any pilot.

  3. Chris Says:

    Interesting thing here…another pilot once told me that if you had to lower the collective twice to stay VFR, you need to turn around or land. That’s exactly what the first pilot did. (But for most instructional flights, we’re flying too low to apply that rule.) Also, there was a good discussion of how HEMS pilots deal with making go/no-go decisions on the JH forum. I extracted the best of the advice and posted it here.

  4. Bill Says:

    you know what amazes me… the fact that we are talking about and with intelligent people. Save yourself man! if the local conditions
    are worse than forecast, or observed, divert, depart … figure out the violation later while you and the crew are alive.. Have we trained to the fact that we are afraid of a violation over flying the aircraft?

  5. Ehud Gavron Says:

    I understand where the IFR flight requirement idea has merit.

    However, IFR flight plans require advance notice (normally 30min) prior to ETD. EMS can’t afford that buffer.

    I don’t know that overworked ATC can resolve this issue (and really all asking for IFR flying is … is having someone else look after you.)

    I think the solution is a little more complicated:
    1. Anticol. system installed on all EMS (fixed-wing and heli)
    2. In controlled space, “lifeguard” callsign given REAL priority, not “on as needed” priority. 1200 squakers are diverted. PERIOD.
    3. In uncontrolled space, the use of a “lifeguard” callsign means EVERYONE ELSE gets OUT OF THAT WAY NOW.

    No more leniency to people who won’t LISTEN to CTAF let alone self-announce. Clearly. Consistently. Often.
    CTAF is not to discuss the latest corn prices. It’s location, altitude, direction, intention, and type [if appropriate].

    Ehud

  6. Paul Jackson Says:

    I appreciate your columns on helicopter flying, flights, system operations and what makes helicopters tick. I am a helicopter owner/pilot and feel helicopters don’t get much attention in this forum. Thanx, again!

  7. Bill Says:

    Wait a minute Ehud, you certainly are’nt serious.. your telling me if over an ATC frequency a “lifeguard” takes priority at all times, .. it couldn’t possibly work..Look, the problem is there are a lot of pilots that shouldn’t be pilots, they are too afraid of saving their ticket vs what the ticket gives them. the ability to fly. Who cares if you declare an emergency, who cares if you get violated. There was a plan, it was a good plan, and it needs to be changed.. change it now or your going to die. The Feds say if your stupid and you declare an emergency you are going to be violated. Don’t you think you should be? by the way i am not a Fed.

  8. Paramedic Pete Says:

    I live in an area covered by 3 areomed services. If ” lifeguard” says “everyone get out of the way.” There would be NO room for any of the rest of us to fly !

  9. Bill Says:

    the EMS industry has taken the spotlight on accidents right? that needs to be corrected right? there has to be a plan, that is where the industry has to go. In WX local conditions take precedence over forecasts and observations. ALWAYS. i realize EMS guys have an additional mind issue they are wrestling with, and that is “saving lives” along with the pressure of making a buck, either for you or the company, right? That’s the rub. If you were to launch, on a VFR flight ,say to grab a bite, and the WX conditions were below VFR rules.. you wouldnt/couldnt/shouldnt go.. Now a flight is dispatched to a scene, and the Guys and Gals know this is what they do for a living they are going to attempt to execute the flight. Before the flight, it was a strategic decision,(it met all the criteria of you being able to operate) once you fire it up and head that way the thinking needs to be tactical. Its interesting because everything i am getting at has been covered in a couple of AOPA pubs that are current, Schiff and the door… fly the airplane from AOPA PILOT, and FALL BRINGS FOG from AOPA FLIGHT TRAINING. it all points back to the get home syndrome. anyhow, I get several heli pubs and this is the problem with the industry. Sometimes you just cant operate.. and its OK to say that. But you as a licensed airman need to say it. Keep in mind the peer pressure maybe great but its your butt!

  10. Ehud Gavron Says:

    I appreciate other people’s opinions.

    I think it’s great you want to fly. I too want to fly and I’m not an EMS pilot. (I’m not yet IFR rated either).

    However, we can take those First Responders who save lives and protect theirs and we can do so by eliminating noncompliant traffic that won’t announce on CTAF, won’t listen on CTAF, and won’t get out of the way.

    You have an issue with it. Fine. Don’t make it personal. I’m suggesting what I think would keep the EMS guys alive… while inconveniencing me (and you) only in a true first-responder emergency.

    If something I said offends you, please don’t take it personally. If you have to take personally, remember you’re on Tim’s forum, and be polite. Sign your name.

    I’m not trying to solve all or any of the world’s problems… except I think these ideas will make EMS helis safer.

    Respectfully,

    Ehud

    E

  11. Retsae Miller Says:

    I am an EMS helicopter pilot and have been flying for over 26 years. I will say for the most part the pilots in this industry are pretty experienced. Also I would say that 99% of the decisions on whether to launch or not is based soley on WX, not revenue or life saving. The other 1% is fuel. I say 1% because most flight requests for a base are in a particular region and that area is usually small enough to accomadate most fuel issues. When unforecasted weather is encountered during a flight it is usually aborted. The problem arises when a patient is onboard. Not only do you have to abort but you have to make arrangements with a ground ambulance service to meet you somewhere and continue the transport. I have done this many times. One issue that is always overlooked is our weather forecasting industry. I have seen it decline in the past 20 years to the point that I DO NOT TRUST IT.
    In my area the accuracy rate is less than 50%. It seems when the human element was taken out i.e. local observers and forecasters and centralized, then later computerized, accuracy when down the “tubes”. The industry lost the local guys area knowledge based on his experience with local phenomenom.TRAGIC. This was all done to save money. So lets quit putting all the blame on the pilots. NTSB and the FAA need to shoulder some of this. We launch with the conditions we are given and then encounter something totally different while we are in motion with a patient onboard trying to figure out whether or not the weather is going to get worse from where we just departed from while we are turning around heading back. If the FEDs supported an intentional IMC recovery procedure vs inadvertant, then there would be no violations and the guys and gals would not be so hesitant to go up. But the FEDs are not willing to take on any responsibilty on any issue. They only point fingures. As for NVG’s. They are great IF you completely understand there limitations and deceptions. Thay can be a double edged sword and get you in as trouble as getting you out. Speaking from over 1500 hours NG time. So what are the solutions? NVG’s, TAWS, IIMC training, FED approval, fix the WX forecasting. All take money. How about some of the stimulus?

  12. Paramedic Pete Says:

    The sad part about air-ems is only about 1 in 10 scene flight really need to be flown. Ems dumps on the flight services so they don’t have to drive long distance transfers. If less BS is flown, less chance of accident . Now areomeds have quick turnaround time because of demand.

  13. Retsae Miller Says:

    I disagree with the 1 in 10 scene flights. That may be true in your area but that is too broad a statement for the whole industry. In my area quite the opposite is true. The ground guys want revenue so they don’t want to call air. Many times first reponders call for air only to get cancelled once ground EMS arrives. Instead they haul the patient to the nearest facility who then calls for air to transport the patient to higher care. Now time is waisted and the patient gets extra uneccesary bills. I don’t mind being launched then cancelled if it winds up being a code green or yellow. Getting us up and running is a good thing just in case. I do agree however that many transfers between hospitals by air are unwarranted. I don’t know if that number would impact accident rates though.

  14. LTE Says:

    I couldn’t agree more with R. Miller. I have flown in the Northern Rockies for a long time and the weather reporting system very unreliable. Our weather changes instantly up here and it is up to the PIC to determine when to turn around or land, that comes with situational aware. You are right where is our Stimulus Package?

  15. Bill Says:

    Retsae, regarding WX. i totally agree. let me suggest that you do not want to give the FEDs anymore authority. remember you are the PIC, you have final authority whether or not to operate. Let’s not give the FEDs to much power delegate and regulate how you interpet the WX and the forecasts.. not being in that branch of the industry, let me ask, on site coordinators, (whatever they are called) do they have the ability to give you all wind, speed, temp, dew point and pressure? if so why cant you interpolate what the weather will probably do? what is the avg stage length in time of an EMS flight? , if they dont have the ability to provide real wx like that why not? there are several hand held tools available. they cant provide cigs and vis but they can
    give you the indicators of what may happen…oh, and btw, dont make the offical WX Observers.. that muddies the water regarding real time, on site local conditions WX. (example, is the guy/gal qualified? is the instrument certified and calibrated.) just use it as a tool for additional info.

  16. Steve Says:

    Wow Retsae Miller, you make very valid points. Without repeating you; I to think are weather service is less that perfect. I also see the weather services simular to the FAR’s in that helicopter operations are just kind of thrown in with that which were specific to fixed-wing only operations.
    I have a big problem with the way our IFR training and procedures are addressed in the helicopter industry. IFR & helicopter operations should not be in the same sentence. We’re not fixed-wing aircraft; we fly unstable aircraft compared to fixed-wing and we should not pretend to be able to use a system designed for them.
    Even the helicopters that have autopilot in an IFR flight are different than the airplane and most helicopter pilots that do try and fly in TRUE IMC conditions and use there autopilot are not familuar with it’s limitations because of the lack of use. IMC/IFR & HELICOPTERS JUST DON”T MIX. IFR in an airplane is very comfortable, but is very uncomfortable in the helicopter to me. Helicopters are flown by feel and visual reference plain and simple. So there’s my soap box.

    We do need a separte system specific to helicopters to deal with inadvertant IMC but continued focus specifically on getting out of it and landing, not continuing. NVG, FLIR, TAWS are fantastic tools, but wont help you in IMC, it’s for night flights to off airport operations.

  17. Jon S Says:

    FIrst of all, thanks for your response Tim. I still agree with you that climbing is the best/safest option in such circumstances, and if the pilot has satisfied the due diligence standard, they should be much more open to that option. In an ideal world, it would be easy for a HEMS pilot (or any of us) to switch from VFR to IFR–get our clearance quickly, receive an efficient routing that won’t strain our fuel, and be able to make our destination–but we all know that it’s far from being like that. I think Steve raises an important point: that aviation resources are really focused on airplanes, with helicopters just awkwardly trying to fit in to that mold (btw, thanks, Tim, for representing–finally we have a voice in AOPA!). Maybe NextGen, including ADS-B, will help helicopters fit into the airplane-centric NAS better, since we’ll be able to enjoy the equivalent of radar coverage even at the low altitudes we fly. How we can get better weather reporting is another problem. We should have better access to the thousands of “unofficial” weather reporting station in between airports, not for official use, of course, but for situational awareness and decision making in the planning stages. Especially since “in between airports” is where we fly.

    Well, I’m rambling. I’m going to be quiet now, but I’ve really enjoyed this discussion. Lots of food for thought. Thanks once again, Tim, for what you do. Also, thanks to Retsae for your inside perspective on HEMS.

  18. Mike Says:

    I’ve been around long enough to know when ever the Government gets involved it will suggest unrealistic solutions. IFR for EMS helicopters? There has never been any IFR approaches to any of the scene’s that I’ve flown into. Mandatory requirement of two Pilots? Most pilots try to keep weight down for performance reasons. Usually we are doing maximum preformance take offs with obstacles. Mandatory Auto pilots and NVG’s great idea. NVG’s? The Feds will not authorize a pilot to descend below 500 feet unless all crew members are using NVG’s. Under 500 feet is where you need them the most. The safety will only increase when the pilots follow the GOM and OPSPECS. If the weather is at or below minimums you don’t go. No one is doing the patient any favors if you have to divert or cancel enroute. When you cancel enroute you increased the response time for patient care. We self anounce on the helicopter frequency when going into and out of scenes and hospital pads. Most helicopter pilots are not even aware of the frequency 123.05 for helicopters let alone monitor it. It is my humble opinion that safety will only increase when Twas, NVG’s and Auto pilots are used by responsible pilots who have courage to say no.

  19. Peter Says:

    As a non-helicopter pilot (fixed wing commercial/multiengine/instrument), but a paramedic and emergency physician, I wonder if there would be a better way to integrate the scene personnel with the weather equation.

    Obviously, the EMS personnel who called the helicopter are seeing the weather on the ground at the landing zone. Presently, none of them have any weather training, but does anyone think they could be efficiently trained to provide reliable (if not very technical) landing zone weather reports. I realize this won’t help for the en route phase, but might still be very useful for the go/no go decision.

    In my EMS experience, if the call is “cool” (as most helicopter response scenes are) there are typically lots of people around looking for things to do. Could this be one of them?

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