Concern Network
Article Outline
- February 12, 2008
- February 14, 2008
- February 17, 2008
- February 21, 2008
- March 1, 2008
- March 6, 2008
- March 16, 2008
- March 17, 2008
- March 23, 2008
- March 25, 2008
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 www.concern-network.org.
February 12, 2008
LifeFlight of Maine (Bangor, ME) was responding to a flight request for a single patient injured in a motor vehicle crash on Route 1A in Holden, Maine, when the safety of the LF1 aircraft and crew was compromised by a driver who willfully disregarded barricades. The roadway, which was extremely icy, had been blocked from both directions by local fire and police vehicles, with fire personnel maintaining watch.
As LF1 approached and performed an aerial survey in their Agusta 109E Power helicopter, they received a radio report from the LZ incident commander. With the LZ security ensured, LF1's pilot landed the aircraft on the roadway. Normally, the pilot would have shut down the aircraft, but due to the extremely cold conditions, short return flight, and unknown patient weight, it was decided to keep the aircraft running.
The medical crewmembers exited the aircraft, per SOP, from the 3 and 9 o'clock positions. While preparing to walk toward the scene where patient extrication was in still in progress, the flight paramedic (FP) turned to confirm LZ safety with the flight RN (FRN) and pilot. At that time, the FP noticed that a private vehicle had compromised LZ security by traveling around the FD vehicle barricade, coming along the port side of the running helicopter, just at the edge of the rotor disc.
The vehicle traveled approximately 10 feet past the front of the aircraft rotor disc and came to a halt when the FP extended a hand and motioned for the vehicle to stop. The driver exited the vehicle, identified herself as a physician, and asked to be informed as to what was going on at the scene. The FP instructed the physician to get back into her vehicle and to stay exactly where she was. At the same time FRN signaled the pilot of dangerous situation by pointing to the port side of ship and indicated that it was safe to lift. The pilot lifted the aircraft back into the air and circled the scene from above until the LZ could be re-secured.
A firefighter escorted the physician to a nearby parking lot, where a police officer was summoned. The physician was then educated regarding the possibly deadly consequences of her actions by the local PD and FD personnel.
Meanwhile, the LF1 med crew initiated care of the patient, who was still being extricated. Once freed, the patient was transported without further problem.
This incident was extensively debriefed with the PD and FD ground personnel at the scene, as well as internally at LifeFlight. The FD has initiated further LZ protection procedures to completely block roadways. For failing to obey a public safety officer, a summons for the physician is pending. No one was injured.
The weather was day VFR conditions with clear skies and extreme cold. EraMed is the program vendor.
February 14, 2008
At approximately 1952 hours, a BK 117 transporting a Children's Hospital of Philadelphia (CHOP) (Philadelphia, PA) team and patient was landing on the helipad on the roof of the hospital. During the final approach, the pilot requested that the lights for the helipad be turned on. While attempting to accomplish this, the safety officer inadvertently activated the foam/fire suppression system. This resulted in discharge of foam and water onto the helipad, with the aircraft inches from landing.
Upon touchdown, the pilot kept the engines at flight idle to help disperse the foam and water, and none entered the helicopter. The patient and crew were aware of what was happening and remained in the aircraft until the fire suppression system was turned off. Other than a delay in off-loading, there was no harm to the patient as a result of this incident. The patient was transported to the receiving unit.
The fire alarm activated with this discharge, notifying the Philadelphia Fire Department. Units did respond and were advised that this was an accidental discharge.
A senior pilot and mechanic reported to the hospital. The aircraft was inspected for damage from the foam and water, and none was apparent.
After a release from the mechanic, the aircraft was powered up, systems were checked, and the helicopter was flown back to its base. After a more thorough inspection it was determined that there was no other damage to the aircraft.
All CHOP staff, medevac crews, and the involved security guards were debriefed by the leadership of CHOP Transport. The switches for lights and foam activation on the helipad are on separate walls and clearly marked. The foam activation switch is also behind a plastic cover with a “screamer” device to alert staff that this is NOT the light switch. Security leadership will be reviewing proper procedures on each shift with all safety officers. A comprehensive review of this system is now underway.
The weather was clear and not a factor. EraMed and University Medevac are the program vendors.
February 17, 2008
Vendor's line service damaged a wing tip light on Lifeguard Air Ambulance's Lear 36. Aircraft was grounded for repair. Patient remained in hospital until aircraft returned to service. There were no injuries. The weather was clear and not a factor.
February 21, 2008
Upon short final into Aniak airport and just prior to landing, the left wing of a Lear 35 belonging to Aeromed International (Anchorage, AK) dipped, causing the tip tank to contact the runway pavement. The landing rollout was normal. Visual inspection showed damage to the bottom of the left wing and tank. Pilot crew indicated the winds were variable and the wind direction was changing (not uncommon for this airport due to surrounding mountains). One medical crewmember complained of left elbow pain after striking it on a cup holder during landing. No medical treatment was necessary. Initial information suggests wind shear as the cause.
Aeromed medical crew assisted with the patient care while a different fixed wing provider was requested to do the patient transport. The FAA released the aircraft for repairs, which were ongoing. Chipola Aviation is the program vendor.
March 1, 2008
About 5 minutes after takeoff, in straight and level flight at 800 feet, a vibration was felt in Memorial Hermann Life Flight's (Houston, TX) EC-145. The left hand sliding door opened uncommanded rapidly at the same time. The crewmember had not touched the door handle. The pilot decelerated slowly, and vibration abated below 60 knots and ceased below 40 knots. The door was loose, but the crewmember held it. The pilot then made the appropriate radio calls and landed safely.
There was no caution advisory display warning of an open door before the door opened. The bottom rear roller assembly came out of the bottom door track.
There were no injuries. The weather was clear and not a factor, and the program is its own vendor.
March 6, 2008
Shortly after departure from a city hospital helipad in class B airspace, the LifeFlight of Maine (Bangor, ME) aircraft avoided a midair collision. The Agusta 109E Power aircraft was cleared to operate along an approved helicopter VFR route when it encountered a helicopter with no external lights displayed. Pilot estimates aircraft passed at less than 100 during evasive maneuvering.
ATC was contacted immediately, and other helicopter was challenged. Pilot responded, “Nav lights are on but the strobes are inoperative but at least the switches are all on (sic).”
The LifeFlight crew was debriefed on the importance of looking for not just the expected but the unexpected as well. The near miss has been submitted to the FAA for further investigation.
EraMed is the program vendor, and the weather was clear visibility unrestricted night (unaided).
March 16, 2008
UVA-Pegasus Medical Transport Network (Charlottesville, VA)'s Agusta109E had recently undergone routine maintenance. There had been several maintenance flights prior to placing the aircraft back in service. The aircraft was placed back in service in time for night shift on March 15.
At 06:22 aircraft responded to inter-facility flight. Outbound leg of the flight was unremarkable. On return flight to University of Virginia Medical Center, the pilot noticed door light illuminated during cruise speed. Seconds after door light illumination, the right cabin door opened abruptly and violently. One crewmember who was out of the seatbelt attending to the patient rapidly returned to belted position and verified security of all equipment. The medical crewmembers' attempts to close the door during near cruise speed were unsuccessful.
Pilot slowed to 30 knots and door was closed and secured by medical crew. When the door was closed and locked, the cockpit door warning light went off, and the flight concluded without further incident.
Prior to returning to the airport, the door mechanism was inspected by the pilot and the door was tested and appeared to function appropriately and was secure. Prior to any further flight activities the crew discussed whether or not the procedure of closing and locking the door and the potential deviations in the process of double-checking security of the doors could have contributed to the door security during this incident. Immediate attention was given to this issue, and the crew took measures to elevate situational awareness associated with door procedure and checklist completion. The aircraft returned to airport without additional door warning lights or door issues. The weather was clear and not a factor.
Maintenance was advised and performed an inspection of the mechanism which appeared to functioning without difficulty. A loose roller was discovered and replaced, although it was not felt that this could be a major contributing factor to the door opening event. The maintenance staff continued to investigate the problem by examining the internal door mechanism in detail and discovered that the interconnection link had unexpected signs of wear. There was noted wear to the pin, which possibly could have contributed to the door incident. The interconnection link was replaced with new parts. The aircraft maintenance staff conducted some additional research into the matter and reviewed a 2003 service bulletin from Agusta regarding door opening that recommended changing the interconnection link. At the time this bulletin was published both cabin doors (on N5UV) had their interconnection links changed.
Since this incident no other issues have been noted with the door. The program has approached the issue with a multi-dimensional intervention. Maintenance staff will routinely inspect internal door handle and locking mechanisms, greater diligence and attention to process detail will be devoted to preflight crew checklist for door handle and equipment security, and the situation has been formally reviewed by the safety committee and information has been disseminated to all staff members. Agusta Westland has been advised of this issue and has been very supportive in further examination of the door components. Worn components have been sent to Agusta who has kept an open dialogue with the program's maintenance staff. Any follow-up information conveyed from Agusta will be disseminated to all staff members.
OmniFlight is the program vendor.
March 17, 2008
Shortly after takeoff from Baltimore Pier at 150 feet and 50 KIAS, a STAT MedEvac (West Mifflin, PA) pilot observed an oil pressure caution light and associated oil pressure loss on VEMD for the BK117C2's number 2 engine. Pilot established single engine flight parameters, confirmed appropriate throttle, and secured the number 2 engine. Pilot continued climb out, declared an emergency, and made an uneventful single engine landing at Martin State Airport.
CEM of West PA, Inc. is the program vendor, and the weather was clear and not a factor.
March 23, 2008
STAR-5, part of STARS Air Rescue (Calgary, Alberta, Canada), was conducting night vision goggle currency training at the Grande Prairie Airport at approximately 2200 hrs. While on the downwind leg, the BK-117 pilot flying remarked that a significant amount of force was required to center the cyclic and that the cyclic would not respond to fore and aft pitch trim inputs. The controls were transferred to the PNF, and the results were duplicated. Centering the cyclic required approximately 10 pounds of force, and the cyclic trim button did not affect a longitudinal change. Continual positive forward pressure was required on the cyclic to prevent an abrupt “spring-loaded” full aft input. The cyclic trim button did permit normal lateral trimming and a corresponding input was noted in the main rotor system. The aircraft was landed and the computerized stability augmentation system (CSAS) and stick position augmentation system (SPAS) were troubleshot as the malfunction was not apparent. No caution lights or other failure indications were present.
Both the CSAS and SPAS test results indicated that the systems were operational. The training flight was terminated and the aircraft was repositioned from the runway to the hangar without incident. Aircraft operation required two pilots to ensure that the appropriate force was maintained on the cyclic to prevent an abrupt full aft input. Engineering was contacted regarding the malfunction and the Emergency Link Center (Comm Ctr) was notified that the aircraft was unserviceable pending further investigation.
Engineering conducted extensive troubleshooting procedures, and a power circuit board was found to be unserviceable.
The program is its own vendor, and the weather was clear and not a factor.
March 25, 2008
A Good Samaritan Hospital EMS (Kearney, NE) crew was en route to transport a cardiac patient from Callaway Hospital to Good Samaritan Hospital when a deer entered the Ford MedTech's path from the left side. The driver applied the brakes and slowed the ambulance from 60 mph to less than 50 mph. The deer struck the center grill and right front quarter panel. No occupants were injured, and the airbags did not deploy. Dispatch was immediately contacted, and another ambulance was sent to complete the transport. No injuries occurred.
The ambulance was drivable and was returned to the garage to await repair. The weather was clear and not a factor.
PII: S1067-991X(08)00104-1
doi:10.1016/j.amj.2008.05.010
