Complex web of factors blamed in HEMS crashes

 - January 27, 2009, 9:13 AM

There is no “magic bullet” solution to the spate of fatal helicopter EMS crashes over the last two years. 

Rather, investigation documents released by the NTSB on January 15 reveal a complex mosaic of multi-level human and technology failures behind nine of these crashes in 2007 and 2008.

Page upon page of interviews, transcripts and forms unveil myriad indirect and direct causes, including “helicopter shopping” by dispatchers. In other words, when one helicopter EMS company rejected a flight, generally due to weather, dispatchers kept dialing until another operator said “yes.” Other factors include pilots assigned, or voluntarily taking, excessive duty time; pilots flying into marginal weather or below safe performance envelopes; a pilot flying injured; and, in at least one case, a pilot with a vision restriction apparently flying without wearing his glasses.

Organizational problems also loom large as at least contributing factors: morale problems, high personnel turnover, maintenance issues, old equipment, failure to install modern safety enhancements such as TCAS, TAWS and NVGs; poor instrument training and currency procedures; and instrument-rated pilots flying IFR-equipped helicopters but not being allowed to fly IFR under the terms of the operator’s Part 135 certificate. 

Some of the more provoking items from the reports include:

May 10, 2008. An Air Methods EC 135T2+ operated for the University of Wisconsin Hospitals crashes in an area of rapidly rising terrain in night VMC on climb-out from La Crosse Airport, Wis.; the pilot, flight paramedic and flight physician were killed.

Other operators reported weather in the area as marginal. Ninety minutes before the crash, the pilot of a La Crosse-based EMS helicopter, dispatched to a scene pick-up, noted fog along the West (Minnesota) side of the Mississippi river and fog and scud forming on the bluff ridge tops to the East (Wisconsin). According to the NTSB, “He stated that ASOS weather reports were usually better than the weather that they actually encountered,” and for that reason he used weather data from two airports West and East for a more accurate report. Citing weather, the pilot declined additional flight requests upon his return to La Crosse.

Further North along the Mississippi, pilots at Mayo Aviation’s Eau Claire, Wis. base also began declining flights citing weather.

Witnesses near the crash site reported weather as reduced visibility with rain and gusts. They reported hearing a helicopter flying low and fast and headed for the bluffs. Searchers reported steady drizzle and significant fog in the search area within an hour of the crash.

The UW-MedFlight program
had undergone several significant changes in the year leading up to the crash; the program and its pilots had transitioned from A109s into the EC 135s, and the program’s operator, CJ Systems, had been acquired by Air Methods.
At the time of the crash the program’s helicopters did not have TAWS.

UW MedFlight was a pioneer in developing special helicopter instrument approaches to its hospital in Madison. The EC 135s were IFR equipped and the program’s pilots are instrument-rated. However, Air Methods decided to bring the former CJ pilots flying for UW onto their certificate as VFR-only. This included the pilot killed in the accident.  

June 29, 2008. Two Bell 407s, one operated by Air Methods and the other by Classic Helicopters, collide while on approach to Flagstaff Medical Center, Ariz. in daylight VMC, killing all seven aboard both helicopters.

Both helicopters were en route from the Grand Canyon area. One had made an intermediate stop at Flagstaff Airport to drop off a crewmember. One helicopter was approaching from the west, the other from the east. Witnesses report that the eastbound helicopter turned southbound into the path of the westbound one. Both pilots had been informed that another helicopter would be approaching the area.
Both were nearsighted but wore corrective lenses. Six days before the crash, pilot Thomas Caldwell, 55, who was piloting the Classic 407, sustained a rib injury in an altercation with a home invader. He was medically released back to work on June 25.

Aug. 31, 2008. Air Evac Bell 206L-1 crashes near Greensburg, Ind., after components of main rotor system separate in flight. The pilot, nurse and paramedic were killed.

The helicopter had just departed a fire department open house when witnesses reported seeing parts of the main rotor assembly depart the aircraft. The helicopter was destroyed by ground impact and subsequent fire.

An examination of the main rotor blades revealed evidence of spar fatigue cracking. The 0.08-inch space between the leading-edge lead weight and the inside surface of the spar was only partially filled with adhesive. According to the NTSB, “The fatigue origin area coincided with a large void in the adhesive.”

Sept. 27, 2008. Maryland State Police (MSP) AS 365N1 crashes in District Heights, Md., while attempting to execute an instrument approach in night IMC to Andrews AFB. The pilot, paramedic, field provider and one of two patients aboard were killed.

The 20-year-old Aerospatiale (Eurocopter) Dauphin was transporting two patients from an automobile accident to a Cheverly, Md. hospital when it inadvertently encountered IMC and attempted to divert to, and acquire the ILS at, Andrews AFB (ADW). The civilian pilot, 59-year-old Stephen Bunker, radioed the tower that he could not acquire the glideslope and requested an ASR approach. The controller responded that he was not qualified to provide one. The helicopter then crashed into trees in a park in District Heights. ADW reported weather as 1,800 broken, seven miles and temperature 21 and dew point 19.

The crash set in motion widespread criticism of the MSP aviation unit and its fleet of older and maintenance-intensive Dauphins, and called some of Bunker’s decisions that night into question. Chief pilot Mike Gartland said he did not understand why Bunker requested the ASR instead of flying the localizer. Gartland told the NTSB that he had recently tightened the unit’s IFR training and currency procedures and that about 65 percent of the unit’s pilots were signed off to fly full IFR, while the remainder were signed off for “recovery only.” Bunker’s latest signoff was “recovery only.”  Gartland said Bunker was a good pilot who would not have launched if he thought the weather would deteriorate.

Gartland said that low pilot pay and frequent leadership turnover have adversely affected the morale of the unit.

The current commander, Major Joseph McAndrew, has held the job since 2006. Since the crash, McAndrew said the unit has increased weather minimums, is evaluating a Part 135 template (as a public agency it is exempt from FAA supervision), adopted a stricter MEL, grounded all helicopters until instruments were checked, and grounded all pilots until they successfully performed an instrument check ride.  

Oct. 15, 2008. An Air Angels Bell 222 collides with a radio tower near Aurora, Ill., in night VMC, killing the pilot, nurse, paramedic and patient.

The 69-year-old pilot, Del Waugh, landed his first commercial flying job in 2004, but had flown helicopters while in the Army in Vietnam. Air Angels hired him in 2006. Following the sudden departure of the company’s chief pilot, Waugh agreed to take a 14 days-on duty schedule, working a 12-hour shift from 7 p.m. to 7 a.m. On the night of the accident, Waugh was on his ninth consecutive duty day.

Air Angels’ check airman, Phil Huth, told the NTSB that Waugh did not appear comfortable with approaches to elevated pads. The accident flight involved transporting a patient from Sandwich, Ill., to Chicago’s Children’s Memorial Hospital. The small rooftop helipad at Children’s is atop the 13th floor (720 agl) and a boom the size of the 222’s would hang over the edge. There are obstructions to the north and northeast. 

A company paramedic reported that Waugh was in a good mood until getting the call to fly to Children’s, after which he became nervous. He told the paramedic that he had never been there before.

The flight picked up the patient and climbed to 1,400 feet. Waugh typically flew with the autopilot engaged. Normal procedure would have Waugh consulting the 146-page helipad facilities directory stored between the pilot and copilot seats about 10 minutes from landing.

Air Angels’ Part 135 certificate did not include IFR operations. The Bell 222 was equipped with a Garmin GNS 430 with moving map. It did not include obstacle or terrain warning displays (although that information could have been loaded onto the system), but was linked to the autopilot. Waugh had corrected near vision.

The helicopter hit the west side of the WBIG radio tower 50 feet below the top, buckling its vertical structure. On the VFR terminal chart, the tower is marked as 1,449 feet msl (734 agl); the information is partially obscured by an airspace boundary line of the same color. 

The coroner found Waugh’s eyeglasses in the pocket of his flight suit.