Submitted by Miles Dunagan, NEMSPA Board of Directors, 10 year HAA Pilot

Every now and then you are asked to participate in something much larger than you realize. Unknowingly you say, “Sure, I’d love to!”, but then you start to feel the gravity of the project, and those you would be representing through your participation. My crew and I took part in just such a project the week before Christmas 2015.

We were invited by the HAI Safety Committee to take part in a project similar to the Pressure Point Videos produced many years ago by the FAA. These videos are scenario-based stories designed to help influence better decision making by air medical pilots and crew members. The idea is to present scenarios for analysis and to identify the points where error-links can be removed from the Accident Chain. These scenarios are presented in a classroom to allow for sufficient discussion of the lessons learned. The scenarios require us to ask ourselves, exactly when do we say, “Enough is enough”, before a cascading series of events carries us to the point of no return.

The Point of No Return – that’s where we never want to be. We want to avoid arriving there at any cost because it means that all other options are now behind us and we are absolutely committed to whatever happens next. But how do we recognize that our current course is taking us there? Sure, we can talk about it, but to truly understand how the law of effect, as well as the law of intensity, can carry us to that point, we have to somehow experience these situations as realistically as possible. If only we could experience these situations without actually being in the aircraft – in deteriorating weather conditions with crew members peering through the fog and rain, wondering when we are going to say, “That’s enough”.

HelicopterFlightTrainingCenter-webMy crew and I traveled down to the Helicopter Training Center in Shreveport, LA to use their Helicopter Flight Training Devices for filming the scenarios. Under the watchful eye of Terry Palmer from Metro Aviation and Dawn Bolstad-Johnson from PHI Air Medical, we embarked on the project.

We flew scenarios that were designed by the HAI Safety Committee. We were informed that the scenarios were all based on situations that countless HAA crews had experienced in the past. The sobering part was that there is a list of names of crews from different companies in different parts of the world who found themselves in these same situations, but did not return home at the end of their shift.

It was also disturbing to be informed that in at least one of the scenarios we would fly, we would not survive.

All of the scenarios were challenging and we were in the “Box” for about 3 hours. Each flight started out pretty much the same except for a few minor differences. We kept our sterile cockpit rules as always. Once we were above our pre-determined safe altitude, we chatted freely, and having my regular crew voices behind me made the situation comfortable. Personally, I had not flown a BA Astar since 1994, but found myself getting familiar with the steam gauges pretty quickly. As we progressed through the scenarios, I tried several different approaches to ensure good outcomes to our flights. I have to admit, I am a Stage 5 Clinger to the notion that the En-route Decision Point, or EDP protocol promoted by the National EMS Pilots Association, can be a game changer when we encounter deteriorating weather. The en-route decision point is triggered by pre-determined pilot responses to reductions in visibility or ceiling. As a pilot, our tendency when we encounter lowering ceilings is to start to descend. The question is how low will we go? Also, as the visibility starts to deteriorate, we slow down. How slow will we go? We set the trigger conditions and once we reach them, we will take one of three actions: 1) We will turn back to good weather conditions. 2) We will land there, or 3) commit to setting up for an instrument approach. What we will NOT do is continue into deteriorating conditions and try to maintain Visual Flight Rules (VFR).

We successfully used the EDP protocol to get ourselves out of bad situations during several of the scenarios that morning. We essentially removed a link from the accident chain, just as EDP had been designed to do and as it has done in actual flights for me and my crews over the last several years.

Be that as it may, I also have to admit that, even with EDP in my bag of tricks, on one of the scenarios I reverted to an old school approach of, “When I feel the hair on the back of my head sticking up I’ll turn around”. I mentioned earlier that we would have to have a bad outcome on at least one flight, and we did. But we knew it was coming, so we crashed the aircraft stoically.

But, on one other scenario, I nearly pushed it too far and put us in the ground again. I pushed so far that my last “out” was almost out of reach and I was very near that Point of No Return. small_logo_piThe weather continued to deteriorate and I thought, “If I just duck a little lower, below the clouds, I would have a clear view.” So I reduced my altitude. Then the weather declined some
more but again I thought if I just duck a little lower, the visibility is clear as a bell so again I reduced my altitude. I had just broken my own rules of EDP. How could this happen? I managed to end that simulated flight by landing in a high school football field. Land and Live is such a simple concept but it is not always easy for a pilot to implement. I didn’t even get to experience a sigh of relief from the safe landing before the flood of emotions poured in. I felt it in the pit of my stomach after finally managing to put the helicopter safely on the ground. As I turned and looked wordlessly at my crew, Scott and Molly, I thought of those we honor at the Air Medical Memorial. Many of them never had a chance to do just that. Pretty emotional, but that was what I experienced.

I must admit, I am as guilty as anybody else who has read an NTSB accident report and asked myself “What were these guys thinking?” I guess it’s human nature. We think it can’t happen to us. Sometimes I think we need to re-cage our attitudes and remember that those crew members we’ve lost drove to their bases completely expecting to go home to their loved ones and live a full life.

Vision_zero_3c copySMALLNow, we need to look at lessons learned. What can we do to achieve that desired number of “ZERO” accidents? My pathway as a professional pilot never led me into the armed forces, but one thing my military trained friends have shared with me is that you fight like you train. I am a firm believer in this concept. My crew and I emerged from that flight training device that day with a different outlook on training. We agreed that we want all members of the HAA community to have the opportunity to train like this. The harsh reality for a flight crew is that if we fail, we fail together. Why would we not want to train for success together? In doing so, we will be working more as a team. Hopefully, we would be more likely to collectively make decisions we can live with.

I look forward to discussing this more at the Air Medical Transport Conference in Charlotte next September. I hope to see you there.