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

July 16, 2011 While a CareFlite (Grand Prairie, TX) crew was en-route from Dallas to Tyler, on a direct course at 3500MSL and approximately 2 NM west of Terrell, the pilot-side chin bubble was illuminated by a green laser from a location almost directly below the Agusta 109 aircraft. The entire chin bubble flashed bright green 3-4 times. ATC was notified immediately.

July 27, 2011 While en route to the Sicily landing zone (LZ), a UNC Carolina Air Care (Chapel Hill, NC) crew, TH1, had a near miss with a C17 transport aircraft. While en route, communication was established with “Range Control.” Around 8 min ETE to the LZ, the pilot in command (PIC) switched to Fayetteville Tower to inform them we were in the area. Immediately after contact, air traffic control advised TH1 of traffic at 11 o’clock and 1 NM. The PIC and flight medic spotted the aircraft immediately, and evasive maneuvers, including a hard climb and bank to the left, were made instantly to avoid a midair collision. The crew debriefed the incident upon returning to Chapel Hill. The fact that the aircraft passed within less than 1 mile of TH1, as well as ways this incident could have been avoided, were discussed. This incident was discussed at the August 2011 safety meeting. Policy will be developed to allow for less time elapsed before placing on network. Noted all actions were appropriate and excellent use of crew resource management.

August 8, 2011 While en route non-emergent to the receiving facility with a patient on board, CCT AL91 was involved in a motor vehicle crash. The Ford E450 Braun Type III CCT ambulance was traveling eastbound on an interstate highway in the right lane approaching its right exit. A motorcycle with 2 occupants in a left lane apparently lost power. The motorcycle driver was maneuvering to the shoulder from the left when it collided with the CCT ambulance at highway speeds, resulting in a hard stop of our ambulance. The motorcycle was able to remain upright and no injuries occurred in either vehicle. The crew immediately called for a PAIP. The communications center dispatch sent local EMS, fire and PD to the scene. AMEICS was utilized (albeit isolated to IC, PIO, and Logistics) and our administrator on call (AOC) and ambulance vendor supervisors responded to the scene. The crew continued caring for the patient, while the EMT driver made initial contact with the 2 parties on the motorcycle, who were uninjured. Upon arrival of local EMS, the patient was transferred to their pram, and the CCT continued on to the origiJanuary-February 2012

nal receiving hospital with both crews in attendance, and the transport was completed without further incident. An initial debrief was conducted immediately after the transport and PAIP. Additionally, a full root cause analysis is in progress. There were multiple witnesses to the accident, and the DriveCam confirmed the accounts from all involved. The driver of the motorcycle was cited. It should be underscored that the patient and equipment were all properly secured and stowed, limiting the damage and potential injuries. Lessons learned include: • Communications—praise was given for the calm demeanor of the crew, who gave a very detailed request of what they needed and specific location information so that the communications specialists could move quickly and efficiently in getting them 9-1-1 assistance. Additional communications were precise, calm, and well orchestrated. • Continuation/coordination of complex patient care—the crew felt comfortable continuing transport on an EMS ALS ambulance to maintain CCT level care on a complex patient. They thought to remember that our electronic pram would not lock in this rig and sheeted the patient over to the EMS pram before transport. • PAIP—all appropriate steps covered included AMEICS use (albeit isolated to incident command, comms, logistics and PIO roles). • Patient restraint use—the patient was properly restrained, including shoulder straps. • Equipment restraint use—all equipment was properly stowed and secured. • Scene safety—the vehicle was moved initially to the far right shoulder for safety and then to a parking area out of traffic once safe to do so. All crew wore reflective vests on scene. • Safety culture and speaking up—all spoke up throughout the event. Most notably, the CCT ambulance was cleared on scene for use by 2 supervisors, appearing to have only minor cosmetic damage. A relief EMT drove the CCT from the scene to base to get back in service and spoke up in the debrief to say he wasn’t comfortable with the ride. Upon further inspection, more significant damage was noted with intrusion into the wheel well with some tire rubbing, and the vehicle was then taken out of service. • Crew coordination/vendor partnership—all expressed good CRM and communication. Also crew coordination and vendor response was immediate and outstanding, including participation in RCA. • Crew restraints—both RNs caring for the patient were in the process of converting the patient to bi-pap on the ventilator when this accident occurred. Both were unbelted to reach equipment. The program continues to e1

troubleshoot location of this equipment to minimize interruption of crew restraint use. We have also had safety committee discussions recently on how we can avoid being unsecured in any transport vehicle and seek to lead others in keeping this a priority. The week before this incident, we began development of a campaign “AIRLIFE wants to keep EMS Alive” that will focus on EMS safety from a variety of angles. It will include an educational campaign designed at sharing literature on emergent response results, CPR effectiveness and outcomes as well as raise awareness with EMS about the use of seatbelts in the back, and several other components. • Sharing lessons learned—a case presentation will be done at the next transport team meeting.

August 3, 2011 During preflight inspection, the HELP Flight - St. Vincent Healthcare (Billings, MT) pilot noted a crack in one of the EC135 P1’s main rotor blades. The aircraft was taken out of service, and a new set of blades installed. The damaged blade was shipped to Eurocopter for evaluation.

August 18, 2011 On final approach to the Boise airport, there was an unannounced shutdown of #2 engine and a “FUEL 2 PRESSURE” warning. An uneventful, single-engine, run-on landing was completed. The new Bell 429 had been received by Idaho Helicopters from Bell the week before. The aircraft was not yet in service with Air St. Luke’s (Boise, ID), and no patient transport was involved. Pratt & Whitney and Bell technicians discovered that a fuel line between the fuel valve and the fuel management module was not properly torqued and came loose, allowing air into the system and causing the fuel pump to lose prime. It is speculated that this may have occurred before delivery, when fuel preservatives were installed due to delays in the completion process. There was no damage to the engine. Bell is investigating their maintenance and inspection processes.

August 20, 2011 While a Life Star of Kansas (Topeka, KS) crew was en route to a Kansas City area hospital, the AS 350 B2 radios and air conditioner began malfunctioning. The pilot made an uneventful precautionary landing at Executive Airport in Johnson County, Kansas. The medical crew accompanied the patient by ground to the receiving hospital without incident. There were no injuries and no damage to the aircraft. Upon inspection, a generator failure was noted, but the warning light on the annunciator panel had not illuminated. Troubleshooting found a faulty data card between the generator and the annunciator panel. Both generator and data card were replaced.

August 30, 2011 The Vanderbilt LifeFlight (Nashville, TN) aircraft was returning to Nashville International Airport (KBNA). While slowing e2

through 190 knots on an extended base leg, 2 large black birds were spotted at the 11 o’clock position. Closure rate left no time for any evasive action. One bird stuck the exhaust stack on the B200’s left engine, partially crushing the exhaust on impact. Engine temperatures and pressures remained normal, and the aircraft landed without any further issues. The aircraft was inspected, and the exhaust stack was replaced. The aircraft was back in service in approximately 4 hours.

September 1, 2011 A Care Flight (Reno, NV) crew was requested to a scene near Gerlach, NV. During the landing, the AS350 B3 aircraft tipped forward onto the toe of the skids. The nose of aircraft suffered minor damage. No other damage was noted to the aircraft, nor injuries to the crew. The patient was transported by ground to Nixon, NV, for rendezvous with another aircraft. Air Methods Corporation was the vendor.

September 11, 2011 Shortly after lifting from a scene en route to the receiving hospital, the EC145 tail rotor gear box chip light indicator illuminated. The pilot attempted to burn the chip following established aircraft emergency procedures, which failed to resolve the chip light indicator. Afterward, the pilot notified the Mayo Clinic Medical Transport - Mayo One Helicopter (Rochester, MN) crew and the Communication Center that they would be making a precautionary landing. A suitable landing zone was identified and agreed upon by all team members and the precautionary landing was executed without incident. The manager on call was contacted by the Communication Center, and the PAIP plan was initiated. Another Mayo Clinic Medical Transport helicopter was in the area, en route to their base, and was immediately diverted to the precautionary landing zone. The medical team caring for the patient transferred the patient into the second helicopter and accompanied the patient to the receiving hospital. The patient transport was completed without further incident or issues. The PAIP plan was activated by the manager on call, and the first conference call was conducted at 1635 hours. Program leadership reviewed the situation and concurred with the action plan. The program mechanic was dispatched to the precautionary landing zone to inspect the aircraft. Upon inspection of the trail rotor gear box, the program mechanic identified materials on the chip detector and removed them. The tail rotor gear box was flushed, and the aircraft was ground run per protocol. The aircraft passed the ground run and was repositioned back to the base. A second conference call briefing was conducted at 1800 with all Mayo Clinic Medical Transport staff. This conference call provided the opportunity for the duty team to debrief the precautionary landing and to brief all program personnel on the event. The aircraft remained out of service until the tail rotor gear box was replaced 2 days later. The Air Medical Journal 31:1

program-supported back-up helicopter was used while the primary base helicopter was out of service.

While a St. Mary’s CareFlight (Grand Junction, CO) crew was in cruise flight at 11.000’ MSL en route to Aspen, CO (ASE), from Grand Junction, CO (GJT), the helicopter encountered a bird strike. The crew, following procedure, elected to abort the flight and return to GJT. Another helicopter was dispatched to complete the patient transfer. The helicopter was immediately taken out of service for inspection by maintenance. Evidence of a bird strike was discovered, and after thorough inspection of the Bell 412EP helicopter, no significant damage was found, and the helicopter was returned to service.

gear box chip light illuminated. No control issues were noted with the EC130 B4 aircraft. The PIC followed procedure and made a precautionary landing in a nearby church parking lot that was a suitable landing zone. AirCom was notified, and the PAIP was activated in accordance with procedure. Appropriate notifications were sent to the program, area, and regional leadership, and local fire and EMS. Maintenance was notified and went directly to the landing zone to inspect the aircraft. The patient transport was completed by a second aircraft that was immediately dispatched upon notification of the precautionary landing. Maintenance inspected the aircraft onsite and cleaned and flushed the chip sensor, per procedure, without further illumination. The aircraft was returned to service and subsequently returned to base. The weather was clear and not a factor. Air Methods Corporation was the vendor.

September 12, 2011

October 2, 2011

Shortly after an AirMed International LLC - Mayo MedAir Medical Transport (Birmingham, AL) crew departed Long Beach, CA (KLGB), the AIR COND FAIL caution light in the BeechJet 400A illuminated and the pressurization system was not operating properly, so the aircraft returned to the airport for an uneventful precautionary landing. The patient was transported back to the originating hospital. Another aircraft was dispatched with a mechanic and the transport was completed on the second aircraft. The pressurization system was inspected and proper operation was confirmed by ground and flight tests.

On the takeoff roll from Chamberlain, SD, at V1 rotation speed, an intense shaking came from the nose of the B200 plane. As the aircraft climbed out, the shaking subsided. The Sanford Health Intensive Air (Sioux Falls, SD) pilots believed they either had a blown nose wheel or a weight in the tire had come loose, placing the tire out of balance. The pilots decided on a plan of action and notified the crewmembers that they would land in Sioux Falls (home base) and that the ground emergency equipment would be dispatched. Proper AMRM procedures were followed, and all crewmembers were in agreement as to the course of action. The aircraft landed in Sioux Falls without incident, and the patient was unloaded and taken to the hospital without any delays. Upon inspection of the nose wheel tire, maintenance discovered that 1 of the interior tire weights had come loose, causing the vibration. The nose wheel was replaced, and the aircraft placed back in service. This is the second time this has happened in the past year, and further investigation is underway as to a possible cause.

September 11, 2011

September 13, 2011 While returning from a transport to an outlying NICU, the Golisano Children’s Hospital Pediatric Transport Team (Rochester, NY) heard a loud bang from under the ambulance. Shortly thereafter debris began to shower the road from the back of the ambulance. The ambulance was traveling at normal interstate speeds, and once slowed and safely off the shoulder of the road, a brief visual inspection showed that the interior tire of the dual rear wheels on the passenger side had shredded down to the steel bands. There was no loss of control. After consultation with the contracted EMS agency management, it was decided to continue 60 miles back to the home base, driving 30-40 mph on back roads.

September 13, 2011 On final approach to Miami Valley Hospital’s south helipad, the Dauphin aircraft flown by a CareFlight Air and Mobile Services (Dayton, OH) crew struck a bird. The pilot continued with his landing. The aircraft was inspected and returned to service because no damage was found. The weather was clear and not a factor. Air Methods Corporation was the vendor.

September 20, 2011 An Air Methods Kentucky (Georgetown, KY) crew was transporting a patient from a referring facility to a receiving hospital. Approximately 8 minutes into the flight, a tail rotor January-February 2012

October 3, 2011 While in cruise flight at 11,500’ MSL from Grand Junction, CO (GJT), to Gunnison, CO (GUC), the Bell 412EP helicopter’s transmission warning light illuminated. The St. Mary’s CareFlight (Grand Junction, CO) pilot also observed a decrease in pressure on the transmission oil pressure gauge. The pilot elected to land as soon as possible. The helicopter landed safely without incident in a field near Crawford and was immediately taken out of service and secured. Upon inspection, maintenance found an external oil jet on the main transmission had become dislodged, causing oil to leak from the transmission. The transmission was repaired on scene and the helicopter relocated to the maintenance hangar for a thorough inspection before being returned to service.

October 6, 2011 The EC145 aircraft was in a descent to a scene request, and the Mayo Clinic Medical Transport (Rochester, MN) crew was e3

in contact with the landing zone coordinator. As the pilot was setting up for final approach, he determined that the force trim release button would neither release nor respond to input. Upon recognition of the situation, the crewmembers and the Communication Center were apprised of the situation. The landing was completed at the established landing zone without incident. Upon shutdown of the aircraft, per procedure, it was declared out of service and the Communication Center updated. Arrangements were made to complete patient transport from the scene by ground ambulance. The patient was transported to the receiving hospital by the on-scene ambulance service with the flight team providing patient care. The patient transport was completed without further incident or complication and, the patient arrived in stable condition to the receiving facility. The manager on call was contacted by the Communication Center. An aviation maintenance technician was also contacted and requested to respond to the aircraft. The PAIP plan was activated by the manager on call, and a conference call was conducted at 0930 hours. Program leadership reviewed the incident and agreed upon the action plan. Upon inspection of the aircraft by the aviation maintenance technician, the aircraft was cleared to be repositioned back to base for further inspection. The force trim release button was found to be faulty and was replaced, and the aircraft was returned to service. Leadership conducted multiple debriefings with all 3 team members on the flight. After completing the debriefing, all Mayo Clinic Medical Transport staff was provided an update via the One Call Now notification system, including the option to contact the manager on call for further information as needed.

October 13, 2011 The Desert Air Ambulance, Inc. (Imperial, CA) crew was returning to base after an interfacility transport. During the initial climb, a sudden unusual vibration occurred in the Cessna 421. The right engine was emitting gray smoke out of the top of the cowling, and a cross-check of the engine instruments was performed. The right oil pressure had dropped to 0, and the propeller was immediately feathered. The tower was notified that there was an engine malfunction, and the pilot requested an immediate return to the airport. A successful engine-out landing was executed, and the aircraft was taxied to the ramp. Upon initial inspection, it appeared that the right engine threw a rod, resulting in complete failure of the engine. This aircraft was out of service until a new engine was installed. A post-incident debrief followed later in the day, consisting of the flight crew, chief flight nurse, chief pilot, director of maintenance, and the safety officer.

October 10, 2011 While Cook Children’s Medical Center–Teddy Bear Transport (Fort Worth, TX) was responding to a call using emergency lights and siren, the 2009 Chevrolet/AEV ambulance was passing heavy stop-and-go traffic on the left shoulder of the freeway. As the ambulance passed a car, the driver of that car attempted to move to the left shoulder and impacted the right side of the ambulance. Due to the center barrier wall, the ambulance was unable to move further left to avoid the collision. The front right corner of the ambulance module struck and removed the car’s side view mirror, and the rear fender flare of the ambulance caused minor body damage to the rear quarter panel and door of the car. Damage to the ambulance was limited to scuffing and paint scratches to the front corner of the module and paint transfer to the rear fender flare. There were no injuries. The Communications Center was notified, and the PAIP was activated. Another ambulance responded to the original call. Local police and department management responded to the scene and a police report was completed. The driver of the car was cited for no proof of insurance, and the ambulance was returned to service. e4

Air Medical Journal 31:1