Concern Network

Concern Network

ARTICLE IN PRESS Air Medical Journal ■■ (2017) ■■–■■ Contents lists available at ScienceDirect Air Medical Journal j o u r n a l h o m e p a g e : h...

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ARTICLE IN PRESS Air Medical Journal ■■ (2017) ■■–■■

Contents lists available at ScienceDirect

Air Medical Journal j o u r n a l h o m e p a g e : h t t p : / / w w w. a i r m e d i c a l j o u r n a l . c o m /

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. The reports are shown here verbatim as they were filed. If you have questions, contact CONCERN Coordinator David Kearns at (800) 332-3123 or [email protected]

5/5/2017 0341 EDT Life Lion Critical Care Transport M.S. Hershey Medical Center 500 University Blvd. Hershey, PA 17033 Type: AS365N3 Tail #: N600LL Operator/Vendor: Own Part 135 Weather: Clear. Not a factor Team: Pilot, Flight Nurse, Flight Medic. No injuries reported. Patient on board. Description: While en route to a receiving hospital the right rear cabin door opened in flight. The crew member closest to the subject door immediately notified the pilot of the situation. The pilot initiated an efficient deceleration to approximately 40 kts which allowed the door to be secured. Noting no further discrepancies and considering the close proximity of the receiving hospital, the pilot and crew elected to continue the short flight to the receiving hospital pad where the aircraft was landed without further incident. Additional Info: Post flight debrief with the crew revealed the crew member did not fully understand the methods that must be used to verify this door type was properly secured even though a “Before Takeoff Checklist” was completed which included a step that verifies and reports “Doors Secure”. In this case, the crew member did not physically put outward pressure against the door to ensure that the upper and lower pins of the door were engaged in the holes in the airframe. This door has hinges located at the rear of the door as opposed to other door types which have hinges on the forward/leading edge of the door It is believed the upper pin (most critical) was not engaged in the hole allowing cruise flight airflow to wedge the door open. A company Hazardous Condition Report was filed and completed. To prevent a recurrence, all crew 1067-991X/$36.00 http://dx.doi.org/10.1016/j.amj.2017.08.005

members have been re-trained on the required steps that must be used to ensure and verify that all doors are properly secured prior to take-off. Source: J. Shouey, Aviation Safety Officer 5/19/2017 0442 EST Indiana University Health LifeLine Type: EC145 Tail #: N197LL Operator/Vendor: Metro Aviation Weather: Clear. Not a factor Team: LifeLine 3 - Terre Haute. Pilot, Nurse, Paramedic. No injuries reported. Patient on board. Description: While in cruise flight at 3000 MSL, a “loud bang” was heard with a secondary “loud rushing” noise. The pilot verified no flight control or system malfunction and initiated a precautionary landing to nearest suitable landing area. After landing, a post-flight inspection revealed a broken copilot chin bubble with bird remains. No occupant was seated in the co-pilot seat at time of incident. The crew was in the cabin area, attending to patient care. No injuries were sustained from the incident and no additional aircraft damage was noted. As a proactive step to assist with avoiding bird strikes, Metro Aviation has begun an initiative to install pulse light systems throughout its fleet of aircraft. Source: Shawn Remick, Manager Operations and Communications 6/25/2017 12:40 EST Parkview Samaritan 11109 Parkview Plaza Drive Fort Wayne, IN 46845 Type: AS365 N2 Tail #: N89SM Operator/Vendor: Mercy St. Vincent Weather: Clear. Not a factor

Team: Pilot, Flight Nurse, Flight Paramedic. No injuries reported. Patient on board. Description: Shortly after takeoff and once in cruise flight from a double patient scene, the left rear wing door opened striking the side of the aircraft. The pilot was immediately notified by the med crew and a precautionary landing was initiated. Once safely on the ground, the pilot immediately surveyed the aircraft and contacted the lead mechanic to evaluate its airworthiness. After the aircraft was deemed flyable, all doors were secured and the patients were safely transported to the receiving hospital. Additional Info: A post flight debriefing was conducted by the safety team, crew involved, and administration. It was discovered that once the first patient was secured on the secondary liter, the PIC secured the right doors and then proceeded to the left side of the aircraft. Upon his arrival to the left side of the aircraft, he found the wing door was already closed with ground EMS personnel attempting to close the main cabin door. The PIC then took over securing the main cabin door and felt that all doors were secured. A pre-flight walk around was conducted prior to takeoff. During the pre-flight challenge and response, all doors were verified as shut and secured by the medical crew members. During our review It was determined that the left wing door pins were never secured into the airframe prior to departure. Source: Chad Owen - Director Flight & EMS

7/10/2017 1731 EST LIFE STAR Hartford Hospital 80 Seymour Street Hartford, CT 06102 Type: BK-117 C-2

ARTICLE IN PRESS 2

Tail #: N145HH Operator/Vendor: Air Methods Corp. Weather: Clear. Not a factor Team: Pilot, Flight Nurse/Paramedic, Flight Resp. Therapist/Paramedic. No injuries reported. No patient. Description: While en route from MidState Medical Center, Meriden, CT, to The Hospital of Central Connecticut, New Britain, CT, LIFE STAR 1 had a VARNR light illuminate and experienced an approximate 30% engine split with #2 engine going low. The aircraft VARTOMs system went into manual mode and the pilot attempted to beep up engine #2 with the collective trim switch with negative results. The collective trim switch would only increase engine #1, which was only done momentarily to check to see if switch was working. Engine #2 would not respond to the collective trim switch. The pilot elected to do a run on landing to KHFD runway 29 as a precaution in order to not exceed any limitations on the number 1 engine. Our Communication Center initiated the PAIP for a precautionary landing. No damage was done to the aircraft and no limitations were exceeded. Maintenance was notified. Additional Info: Upon Further inspection, the collective switch used to match the #1 and #2 engine was found to have an in-

Concern Network / Air Medical Journal ■■ (2017) ■■–■■

termittent contact. The switch was initially cleaned and ultimately replaced later that night. LIFE STAR 1 was placed back in service after the switch was replaced and necessary maintenance test flights were performed. Source: Heather Standish Priest, Medical Crew Manager 7/25/2017 14:00 CareFlight Air and Mobile Services 1 Wyoming Street Dayton, Ohio 45409 Type: Dauphin Tail #: N625CF Operator/Vendor: Air Methods Corporation Weather: Clear. Not a factor Team: Pilot and two flight nurses. No injuries reported. No patient. Description: The crew had just completed a patient drop-off. All three crewmembers conducted a walk around of the aircraft and cited no deficiencies. During the walk around, the left rear door appeared closed with the handle in the locked position and the indoor flag suppressed, indicating the door was locked. Prior to takeoff, the pilot confirmed that no caution or warning messages were displayed that would preclude takeoff. The doors caution light was not illuminated. The pilot re-

ceived confirmation from the crew that they and the equipment were secured. The aircraft departed at 1400. Within 30 seconds of takeoff, the medical crew stated over the intercom that the left rear door was ajar and slowly sliding open. The pilot looked at the caution panel and noted that the door caution light was still not illuminated. The pilot maintained airspeed and obtained permission to land back at the referring hospital helipad utilizing a slow shallow descending bank angle. No equipment damage or medical crew injury occurred as the result of the door opening. The aircraft was landed safely and a second walk around was complete. A crew debrief with leadership revealed that although the door handle appeared to be in the locked position (parallel to the ground) and the red check flag was depressed (symbolizing the door lock was engaged) the door handle latching pin had been extended towards the outside of the door latch rather than inside. Additional Info: All air and ground crews completed mandatory training of the proper closure of the aircraft doors. In addition, a training video had been created by the lead mechanic and aviation manager, and viewed by all crews. Source: Beth Calcidise, Director CareFlight Air and Mobile Services