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. The reports are shown here verbatim as they were filed. If you have questions, contact CONCERN Coordinator David Kearns at (800) 525 3712 or www.concern-network.org.

3/15/13 2200 CDT Life Star of Kansas PO Box 19224 Topeka, KS 66619-0224 Type: AS 350 B2 Tail #: N911KU Operator/Vendor: Own Part 135 Weather: Clear. Not a factor Team: Pilot, flight nurse, flight paramedic. No injuries reported. No patient. Description: On its way back to base from transporting a patient to a Kansas City hospital the helicopter experienced a bird strike to the left sliding door of the aircraft. The bird broke the window, several pieces of which entered the cabin. The pilot determined the aircraft was safe for continued flight and landed safely at our Lawrence base, where the aircraft was grounded. A new window was ordered and installed and the aircraft was back in service about 40 hours after the incident. There were no injuries to the crew and, except for the window, no damage to the aircraft.

3/19/13 1120 MST AirMed University of Utah 50 N Medical Drive Salt Lake City, UT 84132 Type: Pilatus Tail #: N399AM Operator/Vendor: Air Methods Weather: Clear. Not a factor Team: No injuries reported. No patient. Description: A request for the AirMed Rock Springs fixed wing team came in at approximately 1000 on 3-19-13. The request was to transport a patient from Lander, Wyoming, to Salt Lake City, Utah. The transport was accepted after checking all appropriate weather and NOTAMS. The team landed in Lander, WY without incident and preformed a post flight walkaround. Approximately 35 minutes after landing the medical crew returned with the patient. The aircraft was noted to not be in the location where it was parked. The aircraft had rolled back into the chain link fence. The aircraft rudder and internal spar were crushed by the top cross pole of the chain link fence, making the aircraft unairworthy. The aircraft was placed out of service and the sending facility was notified. The patient transport was completed without incident by a local fixed wing company at the request of the sending facility. There was no impact on patient care other than a 30-45 minute delay. Root cause indicates that the pilot applied the wheel brakes, however it was determined that not enough pressure July-August 2013

was used to fully set the brakes. Due to the slope of the ramp the aircraft rolled back into the fence causing the damage. The pilot stated there were no wheel chocks in the immediate area. Wheel chocks were purchased and placed in all fixed wing aircraft and are to be used anytime the pilot leaves the vicinity of the aircraft.

3/19/13 1300 EDT University of Michigan Survival Flight East 1500 Medical Center Dr. Ann Arbor, MI 48109 Type: Citation Encore Tail #: N911UM Operator/Vendor: Pentastar Aviation Charter Inc Weather: 1500 ft. overcast, 2 miles, light snow. Team: 2 pilots, 2 surgeons, 1 perfusionist. No injuries reported. No patient. Description: On descent into Willow Run Airport (KYIP) from 12,000 ft. a Thrust Reverser Unlocked was indicated. The flight crew performed the memory items and then addressed the situation with the abnormal checklist. While addressing the unlocked thrust reverser, an additional warning for a Failed #2 AC Inverter illuminated. The pilot not flying addressed the multiple aircraft system issues with the proper checklists and the pilot flying communicated with ATC. An emergency was declared and the aircraft continued to Willow Run Airport. After the aircraft issues were addressed prior to landing, the medical crew was briefed on the situation and the intentions. An uneventful approach and landing was completed with emergency vehicles standing by at Willow Run Airport. Prior to the Medical Crew departing the airport with the procured organ, the flight crew and the medical crew debriefed the incident. The aircraft was returned to service after Pentastar Aviation Maintenance staff successfully addressed both of the aircraft system issues. Additional Info: The inverter problem was a component failure and the reverser unlocked indication was a wiring harness failure. The two failures are unrelated. It's just bad timing to have both failures on the same leg. The smoothness of the addressing the incident is a compliment to the Flight Safety training that the Flight Crew receives and the AMRM training that all flight and Survival Flight Medical Crews train.

3/23/13 12:00 am Cal-Ore Life Flight 311 Cove Road Brookings, Oregon Type: PA31T Tail #: N716WA e19

Operator/Vendor: Cal-Ore Weather: Clear. Not a factor Team: No injuries reported. Patient on board. Description: After take-off on a patient transport from KCEC to KMFR, the pilot selected the gear up and immediately noticed that the Red "unlocked/in-transit" light remained illuminated. The pilot re-cycled the gear with the same result. The pilot then returned the landing gear to the down position, receiving the normal three green indications and elected to return back to KCEC. The patient was transferred to another company aircraft and the flight successfully completed. All proper notifications were made and there was no adverse impact on the patient or crews. Additional Info: The following morning, the aircraft was inspected and maintenance personnel determined that the nose landing gear hydraulic actuator was slightly out of adjustment due to normal wear allowing the uplock hook to not fully engage. This discrepancy was corrected, the aircraft swung on jacks, test flown, and put back into service. An FAA "Mechanical Reliability Report" was submitted to the governing FSDO.

4/12/13 10:25 PM CST Sanford Intensive Air 1305 W. 18th Street Sioux Falls, SD 57117 Type: EC-145 Tail #: N909SH Weather: Clear. Not a factor Team: Pilot, flight nurse, flight paramedic. No injuries reported. No patient. Description: At approximately 2225 on April 12, 2013, TRAUMA 1 was requested to Brookings, SD for an inter-facility transport. After departing the Sanford helipad TRAUMA 1 was just north of Joe Foss Field when the pilot observed the left transmission oil indication below normal limits. The pilot elected to make a precautionary landing at the nearest safe open area and shut the aircraft down. He notified the Communications Center of his intentions, briefed the onboard clinical staff and landed the aircraft. The PAIP was initiated. Maintenance was notified and proceeded to the aircraft. After confirming the airworthiness of the aircraft, the pilot flew to the Sanford helipad. The transmission oil pressure transmitter was replaced and the aircraft was placed in service. All operations were performed with night vision goggles in use. The pilot debriefed the clinical staff after performing the precautionary landing. Additional Info: A post incident de-brief was held on Tuesday April, 16, with the communication center, management and the flight crew. Protocols and procedures were followed, no further action required.

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4/15/13 1915 EST Cleveland Metro Life Flight 2500 Metrohealth Drive Cleveland, Ohio 44109 Type: EC-145 Tail #: N262MH Operator/Vendor: Metro Aviation Inc. Weather: Clear. Not a factor Team: 2 Pilots, Acute Care Nurse Practitioner, flight nurse. No injuries reported. No patient. Description: Helicopter and crew were on short final to hospital helipad when they aborted the landing after experiencing a large torque split, which didn’t seem to respond to the trim actuator control (beeper trim). The pilots identified the emergency, took corrective action, leveled off and proceeded to climb without exceeding any aircraft limitations. The entire crew, utilizing CRM, discussed an action plan and elected to make a precautionary landing at KCGF. Helicopter and crew landed safely on the ground. The communication center initiated the PAIP, involving Metro Life Flight administration, and a second helicopter was dispatched to continue the mission. Maintenance was notified, the helicopter was inspected and determined it could be safely flown back to base (POV). The VARTOMS was adjusted at POV and the helicopter was put back into service. Additional Info: Additional Info: MLF administration would like to congratulate the entire crew on a job well done. This is an excellent example of a professional crew who knew their emergency procedures, their helicopter systems and limitations and how to incorporate CRM.

4/25/13 1635 CST Ambulancia Aerea Oaxaca Oaxaca, Mexico Type: MD 600 Tail #: XC-AAF Operator/Vendor: Gobierno Oaxaca Weather: windy Injuries: Guillermo Chávez, pilot, fatal Pablo H Vicente, paramedic, fatal Description: After picking up a neonate patient and his father, the helicopter was returning to the Capital city and approximately 5 miles off the city the helicopter crashed. (Please see FlightWeb for additional details.)

Air Medical Journal 32:4