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Chapter Seven opens with a recounting of three tragic air medical accidents. We ask why they happened and look at reasons that we knew permeated our existence, and were dangerous.
The Chapter goes on to describe a late night mission in which a benign set of circumstances creeps up on us, drawing us into what could become another tragic accident.
CHAPTER SEVEN – FLYING INTO WIRES AND OTHER DANGERS
OSHA, the Occupational Safety and Health Administration, part of the Department of Labor, created a graphic showing the most dangerous jobs, as measured by a standard fatality calculation per unit of work. Garbage truck drivers scored 22.8, iron workers 45.5 The Deadliest Catch crews in the Bering Sea are at the top of the graphic at 111.8.
One expert on air medical operations, Dr. Bryan Bledsoe, a prominent emergency physician who has authored multiple studies on medevac helicopter patient outcomes, including the OSHA graph, used the same math for EMS helicopter crews. The resulting danger score: 164, grim testimony to what those of us who fly every night know to be true.
The three accidents presented here go to the essence of our story: medevac flying is prone to danger because crews are driven to penetrate dangerous conditions to save patients. The fatality rate is far higher than in any other segment of commercial aviation.
Pilots study accident reports like doctors read pathology data, doctors looking for biological data that helps them treat their patients while pilots focus on crew mistakes and misjudgments, using them to improve techniques and procedures. These accidents are examples of the dangers that plague air medical flying.
In these accident narratives we search for answers that would help us learn and survive:
· Bad weather was a major factor. In spite of weather information warning of the danger, why did the pilot make the decision to fly?
· Was the pilot’s judgement clouded by exhaustion from long stretches of days on duty?
· Had they been adequately trained in making go-no-go decisions that would keep them safe?
In 2016 on a wet morning in Alabama, an AStar helicopter responded to a call: a car had swerved off a dark, rain-soaked road. The pilot, Chad Hammond, somehow managed to find the accident scene through the fog and rain. Yet, once safely on the ground, instead of staying there until the weather improved, they loaded their patient and took off into clouds that, according to witnesses, were no more than 150 feet above the road.
The ground crew watched the helicopter lift off and disappear. Hammond had to have lost contact with the ground only seconds after takeoff, sealing his fate as well as that of his crew, and the patient.
The NTSB investigates all fatal aircraft accidents in the US. When a crash occurs, a team of highly trained investigators takes charge of the scene and using the latest forensic tools, documents it. Months later, after consulting with experts on aircraft design, flight operations and other disciplines, they publish an official cause. They then combine their findings with others from similar accidents and make recommendations to the FAA to change or add regulations and flying practices to prevent further occurrences.
Their report stated that radar at a nearby Army airfield tracked the helicopter’s flight path. It climbed to 1,000 feet while in a constant left turn. As they climbed deeper into the clouds the rate of turn increased, then the AStar began descending in a steep spiral from which it never recovered. It crashed in a heavily wooded area only a mile from the accident scene.
It was a feat of airmanship that Hammond was able to maintain even a semblance of level flight for the two or three minutes before they crashed. Most of us who flew AStars, if we blundered into the clouds and had to fly on instruments, lasted about thirty seconds before losing control. This is proved over and over again in flight simulators during training, a sobering warning to never lose sight of the ground.
In another tragic accident the pilot, David Cavigneaux and his fellow crew members were flying in a twin-engine helicopter actually capable of flying in bad weather, but Cavigneaux’s employer had not trained him in the use of its all-weather avionics, nor did his employer maintain the avionics for use in flight. Had he been so trained he might have been able to find his way to a safe landing even if it wasn’t his intended destination.
The NTSB report detailed the situation. The weather along the mountainous route from Santa Fe to Tucumcari, New Mexico, was mostly heavy rain and gusty winds that night in 2014, although the forecast called for visual conditions underneath the cloud deck. When the call came in, Cavigneaux was advised that a pilot from another air medical company had turned down the flight because of the weather, but he accepted it anyway. In the medevac world that is a red flag. If one pilot concluded the weather was unacceptable, why did another pilot believe he could safely fly in those same conditions? Was he pressured by his employer to take the flight, a common problem in the air medical business, or did he suffer from am epidemic failing among pilots – ‘I can make it.’
Flying toward Tucumcari, the weather closed in around them. The NTSB recreated the flight using radar tracks of the helicopter with graphic histories of the precipitation superimposed over them. The flight path in the resulting picture wandered between the intense green and magenta radar patches - computer symbology for pockets of heavy rain – as Cavigneaux and his crew flew ever closer to their fateful moment.
Encountering a particularly heavy rain shower Cavigneaux, by then, no doubt worried about his situation as his options closed in around him, circled back toward his original route of flight and, for some unknown reason, started descending. In the following seconds the descent turned into a steep dive. The helicopter struck the sheer wall of a canyon at almost 200 knots, well over the aircraft’s maximum speed limit, and disintegrated in a fiery explosion. Cavigneaux and his nurse and medic died on impact.
Investigators combing through the timelines leading up to the crash turned up another red flag: Cavigneaux had been on duty for fifteen days straight, the last seven of them on nights, the most taxing shift for medevac pilots. On this flight, did his exhaustion prevent him from comprehending the situation was degrading around him? He had a way out – find a highway with car lights and land on it. We’ll never know because he made only one radio call the entire flight, when he reported to his company communications center that he’d departed his base.
In the final accident in our discussion, New Mexico State Trooper Sergeant Andy Tingwall flew out into a stormy night in 2009 when three hikers called for help from the Sangre de Cristo Mountains - steep, rugged terrain with bases of the hills at 5,000 feet above sea level, and peaks above 11,000 feet. He apparently thought he could find a way through the storm, even with rain at all elevations and bone-chilling temperatures at the peaks. Clouds obscured most of the terrain.
The hikers were trapped at the top of a steep canyon, and one of them had broken her ankle. In more normal circumstances, that would’ve been a minor setback, but in the cold, wet weather that night the injured hiker was in serious jeopardy from shock and exposure. They had called for help on one of their cell phones and were routed to the New Mexico State Police Communications Center, who alerted their standby helicopter pilot, Sergeant Tingwall, as well as the New Mexico National Guard Search and Rescue helicopter unit.
Two National Guard Blackhawks attempted to fly to the hikers’ position but turned back because of the weather. These helicopters are large, twin-engine, all-weather aircraft, each flown by two fully instrument rated pilots with a cabin crew of combat-trained rescue personnel.
When they landed back at Santa Fe Airport at the base of the mountains they discussed the bad weather with Sergeant Tingwall, who was preparing to launch in his Agusta 109 helicopter. Though it was equipped to be flown in the clouds, Tingwall had no instrument training - the skills he would’ve needed that night. Trained instrument pilots know better than to push into bad weather without the appropriate planning and ATC clearances.
The hikers called again. The cold was taking its toll. That was when Tingwall announced he was going to fly to the hikers’ location. One of the State Police patrolmen on the scene joined him to act as the rescue hoist operator, even though this officer had no formal training in using the hoist or in any other duties of a helicopter crew member.
They took off about 9 PM and flew into the mountains. Tingwall was somehow able to thread his way through the clouds, reach the hikers and hover in close enough to land. He then assisted the injured hiker into the helicopter.
Then he made the fateful decision of the night, to take off in what the hikers later described as near zero visibility from his landing spot in the mountains where, had they stayed there they would have survived the night, cold and uncomfortable, but alive. As soon as they lifted off they disappeared into the swirling clouds, according to the hikers. The next thing they heard was a loud crashing noise. Clues at the accident scene showed that the helicopter’s tail had struck a rock and destroyed the tail rotor. Spinning out of control, which is what happens when the tail rotor is no longer working, the aircraft crashed into a canyon wall, killing the hiker, seriously injuring the State Police Trooper volunteer and badly injuring Tingwall.
He was able to advise the Communications Center of his situation and request assistance, but by then the weather had closed in. No one, not even ground rescue crews, could reach them. Trapped in the wreckage Tingwall perished from his injuries during the night. Helicopters were finally able to reach the scene the next day and recover the bodies and the injured Trooper.
The NTSB concluded the pilot’s decision to initiate the flight in the first place, and then his attempted takeoff from the hiker’s location in almost zero visibility were the probable causes of the accident.
They also faulted the culture of his department, which “prioritized mission execution over aviation safety,” as well as the pilot’s state of fatigue from so many hours on standby duty.
These narratives present some common errors that resulted in fatal crashes. All of them pilots suffered lapses in good judgment. Was the deep, emotional drive to save the patient driving their thinking? Certainly, fatigue from long duty hours was a factor in the Tingwall and the Cavigneaux accidents. Other factors surfaced - the ‘I-can-do-this’ syndrome, and possibly, pressure from employers to take the flight.
The leading companies in the medevac community have developed training programs that address many of those factors, but the fact is, even with the best training, along with policies eliminating pressure on the pilots to accept missions, what we do, by its very nature, is dangerous.
These accidents happened during the years I was flying medevac missions in Arizona. In the worst year ever for air medical accidents, 2008, 35 medevac crewmembers and patients, including six from the Flagstaff midair collision, died in a rash of accidents unparalleled in air medical history. The NTSB expressed alarm and called for new industry and regulatory initiatives. For my part I wrote a series of articles in the aviation trades highlighting potential solutions. The main one included modernizing our cockpits with technology available in fighter jets and other platforms. Itgenerated some interest and an invitation to speak to a national meeting of emergency physicians, but not much more. The cockpit improvements I proposed would’ve cost more than any air medical company was willing to spend even if they would save lives.
While working with members of the NTSB I was still out there picking my way through the mountains and the rain. Every time I decided to accept a flight when the weather was bad, I was more angry that I allowed myself to be pushed into those extreme situations than I was scared. There would be a day, though, I would reach that point and walk away.
***
Starting in the ‘70s, when jets began taking over from prop planes across the airline community, aviation made steady progress toward safe flying. The ultimate goal has now been attained: In the last twelve years, U.S. air carriers have experienced zero fatalities, except for a Southwest Airlines Boeing 737 that experienced an uncontained engine fan failure in flight. That flight landed safely. All the passengers and crew were unharmed except for one passenger who received fatal injuries from engine shrapnel.
This safety record is a phenomenal accomplishment that, for some reason only the media knows, isn’t near as well publicized as it should be. Despite the crowded conditions on modern jets, poor service and lost bags, the traveling public is statistically safer in a cramped seat on a commercial plane than anywhere else they could be, including their own homes.
The hard lessons learned in aviation over past decades that are now fundamental to the world of flight form the technology and human science core of this miraculously safe travel environment. Pilots, aided by the latest technology displays, information management and flight control systems, fly with a perfectly clear world picture. That in itself is a major contributor to safe operations.
Along with these inflight technologies today’s pilots operate within an advanced ATC and operational environment that assures a near-perfect flow of flight information as well as access to instant advanced technical expertise should unforeseen technical problems occur.
All segments of aviation today enjoy these technical and operational benefits, including safe flying every day, except medevac operations. The weather, often as not, is a complete unknown, as is the landing zone. We have no idea what to expect - high trees, rocky cliffs overhanging the landing spot.
Arriving overhead the scene, chosen by ground responders who may or may not have been trained in arranging landing zones, it’s up to us to figure out the local obstacles - wires, fences, and stray tree branches. So, we fly carefully defined recon patterns while we search out hazards and define a safe arrival pattern. Jet pilots, in contrast, use precise 3D depictions of destinations they pull up in flight from onboard databases.
There was a night when the picture of the landing zone we got from the ground crew was horribly flawed and we came within a hair’s breadth of being killed. It was a mission in a place far from California, another medevac program after things at UCLA went wrong for us.
The Medical Center’s revenues plunged as it struggled to cope with lower reimbursements from insurance companies who, intent on increasing their margins had formed Health Maintenance Organizations, HMO’s to force cost pressures on hospitals.
This was my first experience with what would become a decades-long challenge for health care in the US. As HMO’s pressed for more and more cost cuts, hospitals were forced into making massive program cuts just to stay in business. Our UCLA Aviation Program was one of its victims.
After ten years saving hundreds of lives, we were shut down. The nurses, who were all senior medical staff, simply returned to jobs within the Medical Center, displacing more junior nurses. The pilots were terminated at a time when flying jobs were near impossible to find. We scattered to the four winds and survived as best we could.
I had invested a lot of myself in this project and took the closure as a personal failure. Ever since then I’ve looked back and asked myself what I did wrong to put us in management’s crosshairs. Was it the long flight to Montevideo, when I overreached? Were there other decisions I made that brought scrutiny on us.
I asked my friend Marshall Morgan if my mistakes had cost us the program. His ever so kind reply was that no, the politics were such that it was inevitable. Still those unanswered questions and their burden, and the pain of loss for all of us who so proudly served there, will haunt me forever.
Bronson Hospital in Michigan was the next stop for me. The 222 was a beautiful patient ship, but Bronson flew its big brother, the 412, a Vietnam-era Huey fuselage with a modernized rotor system, two powerful engines replacing the single one in the old Huey, and updated avionics in the cockpit. Capable of carrying as many as six patients, it was the ultimate medevac helicopter.
The 412’s cockpit looked like the corporate jets I’d flown, complete with a sophisticated autopilot and a full complement of instruments and navigation gear. The aft cabin housed an advanced medical suite surpassed only by those in combat rescue helicopters.
To get into the cockpit you climbed up a step on the landing skids, then opened a big door, like mounting a tactical battle vehicle. After you adjusted the array of seat controls for a perfect fit, you were as comfortable as you would be in a jet. The best part came later, when you went flying. The 412 was a pilot’s joy.
That morning about, three AM, the nurses and I flew through a string of rain showers to the scene of a bad auto accident. Arriving overhead, we spoke by radio to a fire fighter on the ground about the local conditions. The vital question: Where were the obstacles, what were they and how high?
Our biggest fear was high-voltage power lines. They’re hard to see, especially at night, and potentially deadly. At that point in history several medevac helicopters had flown into wires they never saw. They ripped through the airframe, exploded the fuel and sent the aircraft plummeting to the ground in a ball of fiery debris.
“County Fire, Airmed One, looks like a good LZ on the highway,” I said over the radio.
“Yessir, it’s plenty big enough for you,” a fire fighter answered.
“I’m not seeing any obstacles around it. Can you confirm it’s clear?” I asked.
A long silence followed. Whoa, what was that all about? Was he checking around, or what? Then he answered: “Uh, it’s all clear down here, sir.”
The pause was not good. More than likely he hadn’t looked for obstacles and now didn’t want to admit it. This locale’s volunteer fire fighters weren’t trained on how to handle helicopters or how to set up landing zones. What was really down there?
Should I fly a circuit and check out the scene? But then, we’d already flown all the way around the place getting lined up for the approach. I’d seen the whole picture, hadn’t I? Still, something ate at me and I wasn’t about to commit to a landing until I calmed my nagging fear.
The nurses chimed in over the intercom that we needed to get on the ground. I remained silent while I came up with a plan.
The 412 had two big searchlights. I could point their beams out in front and downward, right at the landing spot, two brilliant shafts of light guiding us down the descent path. If anything showed up in the light beams, I could pull up and fly away, save us from disaster.
They were arc lights, so after I flipped the switches on, it took a few seconds for them to build up to their full power. But, once they did, their 35 million candlepower pierced the night with god-like beams that flooded the highway with an intense glow. Even in the rain, it was like high noon down there.
I lined up for the approach then slowed the 412 to what they taught us in flight school should appear as a ‘fast walk’. We began a steep descent right down the light beams. I watched our progress through the small windows near my feet, the chin windows. The helicopter shuddered and rattled, unhappy with our low speed as we settled toward the highway.
Suddenly, horizontal flashes appeared in the light beams. They were long, bright, and metallic. In an instant I knew - wires, gleaming in the light. I added power and we climbed away. The hair stood up on the back of my neck as I watched the wires slide by right underneath the belly - big, thick strands of steel that would’ve sliced through the helicopter and turned it into a flaming coffin.
“Woody, where are we going?” said Mary, one of the nurses. “We need to get down there. One of the victims is bleeding out.”
“I understand, Mary, but, if you look out the window you’ll see a big set of power lines the locals forgot to tell us about,” I replied, carefully articulating each word to control my shaky voice, the cold fear still jolting through me.
I heard them whispering to each other over the intercom as they saw the wires. They were quiet after that.
This time around I planned to land farther down the road from the towers and fly slowly along the highway, underneath the wires to the landing spot. Suspended several stories above the highway, there was plenty of room for us to hover up the road a few feet off the ground and pass under them.
Soon we were parked on the highway, the nurses out taking care of their patients. I sat in the helicopter with rotors turning, my boot holding the door open. The rain had slowed to a steady mist, the rotor wash blowing it outward in a damp cloud.
A small man in a baggy fire fighter outfit came up to the door. Holding on to his bulky fireman’s hat against the rotor blast, he raised his voice over the noise.
“Hey, sir, how ya doing?” he said. “How come you had to fly around like that instead of just coming in to land?”
I was still shaken from our near-death experience and angry at the ground crew for not telling me about the wires. The answer that was on the tip of my tongue was ugly. Then I looked down at this little man in his ill-fitting uniform, twice the size he should’ve worn. Rain water soaked his face and dripped off his cheeks onto his overcoat. He looked at me through honest open eyes, his gaze one of admiration and respect.
His volunteer fire company more than likely was underfunded and used hand-me-down equipment, yet he was out here in the middle of the night getting soaked to the skin and blown around by the helicopter, doing his duty.
I bent down to him so he could hear me better. “There’s a big set of power lines right back up the highway there, so I had to abort the approach and figure out a different way in.”
He looked past me in the direction I was pointing and saw the wires. His eyebrows shot up and his jaw dropped. Then he shook his head. Slowly he looked up at me.
“Man, I am so sorry. We had some badly hurt people here and needed you guys on the ground. I just didn’t see the wires.”
I put out my hand and he took it in his soggy, gloved hand. “This is a dangerous business, my friend. We can never be too careful.”
I asked him if his department had ever taken the landing zone class our unit offered first responders. He shook his head. I gave him a business card and suggested they call us.
By then, the nurses had returned and were loading the patients. The fireman and I shook hands again, he holding on to mine for an extra moment or two, his eyes thanking me. Then, he stepped back to give me liftoff hand signals.
I had made a friend for life. We didn’t fly into that neck of the woods often, so it wasn’t likely I would ever see him again, but later on, other pilots who did land out there came back saying that the locals gave them an unusually warm welcome.
That night was a profound experience. Some instinct or subconscious warning raised a red flag within me: stop and re-think this landing approach. Had I ignored it, easy enough to do in the press of a late-night flight, and blithely trusted the fire fighter’s report, we would’ve flown into those power lines and died. It gave me pause.
In the years after that night we would see ever-increasing pressure on costs as insurance companies exerted more and more control over medical care. It would add to the danger, and probably the number of deaths of medevac crew members. Pilots’ intuition would become an increasingly price.
Copyright © 2021 Woody McClendon. All rights reserved.
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