Concern Network

Concern Network

Concern Network The Concern Network shares verified information to alert medical transport programs when an accident/incident has occurred. Both air a...

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Concern Network The Concern Network shares verified information to alert medical transport programs when an accident/incident has occurred. Both air and ground programs are encouraged to participate. If you have questions, contact CONCERN Coordinator David Kearns at (800) 525 3712 or

October 20, 2009 While en route to pick up a patient for an interfacility transfer, at approximately 4,800 mean sea level (MSL), a Carilion Clinic Life-Guard (Roanoke, VA) flight nurse noted lights approximately a quarter-mile away and 4,000 MSL heading toward the EC145 aircraft at the 3-o’clock position. The flight nurse was using night vision goggles (NVGs) at the time, in the forefacing seat behind the pilot. The nurse advised the pilot of his observation as he looked under the goggles to confirm. With visualization of the military jet, the Life-Guard pilot immediately turned the white side strobes on, subsequently advising the other aircraft to bank and climb. A second military jet was noted at that time, but it was considered to be of no issue. The team discussed the incident while en route to the sending facility and agreed to continue. A formal debriefing with the pilot, flight nurse, and flight medic was held after transport completion. The team again debriefed at the end of the shift, with the program director and program safety officer. Several air traffic controllers (ATCs) /military base operations and flight service stations were subsequently contacted to attempt to discuss the incident, but no one could confirm military aircraft presence in that area. The weather was clear and not a factor; Air Methods is the vendor. The incident occurred in the Pearisburg, VA, area. According to the flight nurse, the lights may not have been observed and confirmed as an aircraft without NVGs. Similar lights are frequently observed with ground traffic on the mountains. This base implemented NVGs in August 2009. It was noted that because NVGs can hinder some visual cues and distance estimations, the flight nurse was appropriate to quickly confirm the traffic unaided as well. The incident occurred in a non-radar environment, and therefore the Traffic Information System on the aircraft did not reveal any traffic. This incident occurred in an area where military IR/VR routes are documented. Military aircraft have been noted in this area before, most recently approximately 1 week ago; distance and separation were a non-issue. Lessons Learned: • When used appropriately, NVGs are effective in identifying obstacles, especially in mountainous terrain. • The flight crewmembers’ “Eyes Out of Cockpit” allows quick identification of the incoming traffic. • The pilot’s quick decision and action to turn on the side white strobes can provide the other aircraft immediate visualization and subsequent evasive action to avoid a collision (note that these side white lights are not used as a standard during night operations because March-April 2010

of the potential of strobes causing vertigo and interference with NVGs). • Standardized callouts (“traffic 3 o’clock low”) provide the essential information in the quickest means possible, optimizing reaction time.

October 22, 2009 A Tristate Careflight (Bullhead City, AZ) aircraft was en route to a receiving facility from a scene call. At 4500 feet MSL in cruise flight, the Agusta A119 pilot felt an unusual vibration and a decay in rotor revolutions per minute. At this point, the aircraft entered an autorotation, and a hard landing occurred. The crew and patient were safely evacuated from the aircraft with no injuries from the landing. The patient was relocated to an appropriate landing zone, where another Careflight helicopter completed the transport to the receiving facility. The patient was transported without incident. The weather was clear and not a factor.

October 30, 2009 After completing a mission, while en route back to base, the Metro Life Flight (Cleveland, OH) crew noticed a burning smell accompanied by light smoke. This smoke was immediately followed by a series of caution advisories involving the Sikorsky S-76’s transmission and servo systems, along with noises and vibrations. The pilots conducted an emergency landing to a large open field. Position reports and the safe landing were communicated to Metro Flight Communications Office. The approach and run-on landing were uneventful, and the crew exited the aircraft without injury. After landing, smoke and fire were noted through the #1 engine intake. The crew responded with onboard and portable fire extinguishers, quickly extinguishing the fire. The weather was clear and not a factor. The local fire department was able to quickly respond and locate the crew and aircraft because of ongoing communication of location and situation between the pilot not flying and the flight communications office. The crew also attributed the successful outcome to shift briefing practices, prior simulator training, and effective crew resource management. The aircraft was relocated to the maintenance base and underwent inspection by the company, manufacturer, and Federal Aviation Administration (FAA) representatives. Metro Aviation is the vendor.

November 2, 2009 While en route to a transferring facility to pick up a patient, an Avera McKennan Careflight (Sioux Falls, SD) aircraft struck at least two ducks, with one coming through 71

the copilot’s side of the windshield. The duck struck the medic on the left knee and then continued back, striking the left side med wall, and splattered throughout the medical crew area of the EC145. The medic suffered a small minor cut on that knee. The aircraft was at 1,200 feet above ground level (AGL). The weather was clear and not a factor; Omniflight Helicopters is the vendor. Along with the skill of the pilot, the crew credited the NVGs with allowing them to find a suitable place to land while in the dark flying over trees, cornfields, and numerous water-filled sloughs. Also, our dispatch center, which was tracking the aircraft through Outerlink, had emergency personnel en route to the area berfore the aircraft touching the ground. Note: NVG training was completed just 2 weeks before the incident.

November 2, 2009 While a Dell Children’s Critical Care Transport Team (Austin, TX) was en route to a receiving facility, with both the patient and the patient’s mother on board, the Ford E450’s rear axle broke at highway speed, causing both driver’s side rear tires to come off the vehicle, dropping it down onto the rotor. The driver was able to maintain control of the vehicle and safely clear from the interstate. There was a brief fire in the left rear compartment that self-extinguished. A backup ambulance was dispatched, and the rest of the trip was completed safely. The weather was clear and not a factor. The nurse and respiratory therapist were attending to the patient at the time of the incident and were not buckled in. At a team meeting, the need to be buckled in when not performing patient care and the importance of securing all equipment within the patient care area was discussed.

November 8, 2009 At approximately 1:30 pm, a Children’s Hospital Boston (Boston, MA) team was traveling in a private Ford 350Medix ambulance north on route I- 93 in New Hampshire when the driver abruptly slowed after he noticed a deer scampering across the highway. The deer’s rear end was struck by the front left quarter panel of the ambulance, producing a “thump” within the cabin. The driver immediately pulled the vehicle over to the side of the road as the deer hobbled away. All four passengers had their seat belts on, and all equipment was properly secured at the time of the incident. Inspection of the ambulance showed it to have a small dent where it struck the animal, but otherwise it appeared to be mechanically sound. The emergency medical technician reported that he had been traveling at approximately 70 mph. He was advised to travel within the speed limit. The call was completed without further incident. The weather was clear and not a factor. The communications center, private ambulance service, nurse manager, and mechanic were all notified at the time of the incident. The safety officer and medical director were notified the following morning. The incident was reviewed with all parties and the private ambulance service. 72

November 9, 2009 North Colorado Med Evac 2 was on a patient transport from Yuma, CO, to Denver, CO. At approximately 5:50 pm, the aircraft was westbound at approximately 1,200 feet AGL when the medical crew heard an unusual whining noise emanating from the Bell 407 engine area and immediately notified the pilot. The pilot, in consultation with the medical crew, made a decision to make a precautionary landing (PL) and initiated a descent. After initial reduction of the collective, the engine chip light illuminated, and the crew selected an appropriate PL site in a field adjacent to a road. The pilot executed a descending 90-degree turn into the wind and set up for a final approach into the selected landing area. During the descent, the pilot instructed the medical crewmembers to activate the ISAT emergency switch on the satellite phone and to contact dispatch and advise them of the situation. While on short final approach, at approximately 10 feet above the intended landing point, the crew saw a flash, and the engine failed. The engine failure was accompanied by a yaw and the associated aircraft warning/segment lights and audio alarms. The pilot executed an autorotation to the intended landing point with no damage to the aircraft or injury to the patient or medical crewmembers. The patient was transported by another helicopter service, and the pilot and medical crewmembers were transported by aircraft back to their home base. The FAA and National Traffic Safety Board were notified. The Denver Accident Investigation Supervisor conducted an on-site investigation and released the undamaged aircraft. The aircraft was subsequently recovered to a Metropolitan Transportation Commission facility and is being evaluated in conjunction with the Office of Emergency Management regarding the cause of the engine failure. The immediate and decisive action on the part of the pilot and medical crewmembers, the application of sound CRM practices/principles, and application of hands-on emergency procedures training played an integral role in the safe outcome of this occurrence. Med-Trans Corp is the vendor.

November 12, 2009 A Critical Care Transport (Birmingham, AL) aircraft struck a bird on final approach into Dothan, AL, at 5,500 feet, impacting the Cessna Bravo nosecone. A thud was felt by all on board, with blood spatter on the windshield. The team and patient were transported by backup aircraft. The weather was clear and not a factor. There was no internal structural damage; the radome was replaced, and aircraft was returned to service the following morning. LifeGuard Transportation Services is the vendor.

November 16, 2009 The AirMed Hawaii LLC (Honolulu, HI) aircraft departed Honolulu at 10:50 am HST to reposition to Hilo. Northeast of Kona, HI, the King Air C-90 was in cruise flight at 15,000 feet when the right engine began to lose Continued on page 77 Air Medical Journal 29:2

Concern Network Continued from page 72 power. The captain followed company procedures and completed the procedures for a precautionary engine shutdown. The flight crew notified the ATC of their intention to divert to Kona, the closest appropriate airport with crash, fire, and rescue equipment on standby. An uneventful single-engine landing was performed. A second aircraft was dispatched to retrieve the crew and to position maintenance personnel for an on-site inspection. Maintenance determined that an internal failure of unknown cause had occurred with the engine, and they replaced it with a zero-time engine. The weather was clear and not a factor.

November 17, 2009 On an EHS Lifeflight (Halifax, Nova Scotia, Canada) flight, the engine chip light on the #2 engine illuminated during the approach to land. The checklist was followed, and the Sikorsky S-76 was landed without incident at Halifax International Airport (home base). The #2 engine chip detectors were inspected. A few small flakes were observed on the forward chip detector. The chip detectors were cleaned and reinstalled, and a 30minute ground run was carried out with no anomalies.

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Engine oil was drained and replaced. The aircraft was ground run, leak checked, and returned to service.

November 27, 2009 During takeoff, Warbelow’s Air Ambulance (Fairbanks, AK) medical crewmembers reported an unusual sound emanating from the port-side engine of their Piper Cheyenne XLII. During climb-out, the pilot observed that he was unable to increase torque on the port-side engine. The pilot remained in the traffic pattern for the airport and requested permission to return to the field. The aircraft was landed and taxied back to the hangar without incident. The weather was clear and not a factor. Subsequent investigation found that a microswitch in the propeller assembly was out of adjustment and prevented the port-side propeller from advancing out of feather. Maintenance personnel resolved the issue, and after an uneventful test flight, the aircraft was placed back into service. After returning to the hangar, the crew prepared to launch another aircraft on the mission. The weather at the destination rapidly deteriorated while preparing a backup aircraft, and the flight was delayed. The backup aircraft launched a few hours later on November 28 to pick up the patient and deliver to definitive care. No adverse patient outcome was evident because of the delay.