Concern Network

September 14, 2008 

University Hospitals MedEvac (Middlefield, OH) turned down a flight request for weather because of thunderstorms and high winds (47 knots). Patient instead was transported by a Ford ground ambulance from Geauga Medical Center, Chardon, Ohio, to Case Medical Center in Cleveland. En route, a flight paramedic briefly unlatched his seat belt to change an intravenous bag when the ambulance driver applied the brakes abruptly to avoid hitting a tree limb on road. Flight paramedic was thrown forward and received injuries to head, back, and shoulder. No other persons were injured.

The team called 9-1-1, and the paramedic was transported to a local Level II trauma center by the local fire department squad, and the original patient was transported by the ground ambulance crew to Case Medical without further incident.

The paramedic was hospitalized for 2 days and released. He is still receiving treatment and has not returned to work.

September 24, 2008 

The Carilion Clinic Life Guard's EC 135 aircraft was en route from Roanoke, Va, to Christiansburg, Va (Life Guard 11 base), after completion of a public relations event. En route, a transmission chip light illuminated. Per Eurocopter guidelines, the fuzz burn procedure was completed with success. The light illuminated a second time, and the fuzz burn procedure was again used, without success. The decision was made to make a precautionary landing. A church parking lot was immediately identified as the most suitable landing area. The weather was clear and not a factor.

The Carilion Clinic Patient Transportation (CCPT) Comm Center was notified of their intentions, along with the current latitude/longitude coordinates. On landing, the flight paramedic confirmed the name of the church and called the CCPT Comm Center via cell phone. The Comm Center notified local police for assistance with securing the landing zone. The CCPT medical crew was picked up and transported via ground to their base by the CCPT director for ground emergency medical services.

The mechanic was dispatched to the scene. The oil was changed and the gear box flushed, followed by a 10-minute penalty run and a 5- to 10-minute penalty hover, as per the maintenance manual. The aircraft was then placed back in service, per manufacturer guidelines.

On the initial flight to Roanoke from the base in Christiansburg, the same chip light illuminated. The fuzz burn procedure cleared the chip light. The aircraft was inspected by maintenance staff, and the helicopter was flown locally without the chip light activating.

A debriefing with the medical crew and administration, along with Air Methods pilot and mechanic representatives, was completed.

October 7, 2008 

Airlift Northwest's (Seattle, WA) Airlift 2 with was en route to an area hospital and experienced a bird strike to the Agusta 109E's main rotor blade. The pilot aborted the flight and returned to base at Boeing Field in Seattle. The aircraft was taken into the hangar for inspection by the base mechanic and was cleared and placed back into service. All of the flight crew was flying with helmet visors down. The weather was clear and not a factor. Air Methods is the vendor.

October 11, 2008 

The Community Medical Center (Missoula, MT) team was attending a public relations event at a local fire department field location for a search and rescue training day. The physical location was next to a river in a canyon area. On completion, the AS350B3 helicopter lifted and initiated a departure to the west into the wind. During the climb out, contact was made with unmarked distribution wires that stretched across the river and that had not been spotted during the low reconnaissance before landing. The quarter-inch wires contacted the windscreen, causing minor damage. The pilot maneuvered the helicopter to a clear area and shut down to assess for damage. The incident was reported, and an investigation was initiated.

The crew has been debriefed and assisted with their concerns about this event. The weather was clear and not a factor. Careflight is the vendor.

October 15, 2008 

A Bell 222 belonging to Air Angels Inc. (Bolingbrook, IL) crashed on this day. The program lost three crewmembers—Pilot Delbert Waugh, Nurse William Mann, and Paramedic Ron Battiato—and a patient. The program is its own vendor.

October 18, 2008 

An EC 135 flown by Carilion Clinic Life-Guard (Roanoke, VA) was en route to a public relations event in Dublin, VA, from their primary base at Carilion New River Valley Medical Center in Christiansburg, VA, when caution lights indicated Full Authority Digital Engine Control failure. The pilot decided to return to the base with a 2-minute ETE at that time. While on final approach, and while monitoring the torque on the engines, the pilot decided instead to land at the local airport (New River Valley Airport, Dublin, VA) in the event that an engine would overtorque, requiring a run-on landing. The airport had a 5-minute ETE at that time. The Communications Center and airport were notified. An uneventful precautionary landing was completed without incident. The weather was clear and not a factor.

A Radford, VA, CCPT ground ambulance was sent to the airport in case the crew needed transport back to their primary base. The on-duty mechanic assessed the situation and followed recommendations from the Eurocopter tech reps. When the NG sensors were cleaned and swapped from engine to engine, the issues resolved, and the aircraft was relocated to the primary base without further issues.

The only previous flight that day was a relocation from the lower pad to the upper pad. No issues were noted at that time. The mechanic had been in earlier that day for routine maintenance, and no issues were noted. This was the pilot's first week as pilot in command (PIC) with the program on this aircraft.

A debriefing with the medical crew and administration, along with Air Methods pilot representatives, has since been completed. The communications specialist and flight crew agreed that the recently edited Post Accident Incident Plan (PAIP) process was much more streamlined compared with previous plans. These changes were made in response to a precautionary landing on September 24, 2008. One additional area of opportunity was noted, quicker notification of the Air Methods Operational Control Center.

October 18, 2008 

Life Flight (Missoula, MT) was inbound to the trauma center with a patient on board from a scene call 120 nautical miles out. The Astar 350 B3 pilot suspected fuel indicator problems and was closely monitoring the fuel supply. Seven minutes out from the hospital, the “fuel low” light illuminated. The pilot elected to make a precautionary landing as soon as possible. The weather was clear and not a factor. Metro Aviation is the vendor.

Dispatch was notified, and the landing was completed without incident. The medical crew and patient completed the transport by ground ambulance.

Our mechanic brought sufficient fuel to the helicopter to allow it to be flown the short distance to our hangar. A broken wire and a faulty resistor were found. This caused the fuel indicating system to show 15 gallons more at the beginning of the flight than was actually on board.

October 23, 2008 

A CCPT (Roanoke, VA) ambulance was transporting a nonemergency patient (no lights/no siren) from an area hospital discharge to a rehabilitation facility. The Ford E-450 modular ambulance was approaching a light-controlled intersection in the right lane of a four-lane highway. A passenger car was traveling in the left lane, slightly in front of the ambulance. The light was green for both vehicles. While passing through the intersection, the passenger car began to merge to the right into the path and space of the ambulance. The ambulance driver started to brake and cautiously ease the vehicle to the right to avoid impact. Though impact was avoided with the vehicle, the ambulance struck and rode up on an elevated curb on the right shoulder of the road. This sudden change in movement caused the unrestrained patient care aide (PCA) sitting on the side-facing bench seat to strike the bulkhead, breaking a Plexiglas window and then falling into the curb-side door well. The other vehicle involved failed to stop and proceeded with traffic.

The ambulance driver stopped and notified our Communications Center, which then activated our ground PAIP plan. Local emergency services were dispatched, as well as additional units from our company.

The attendant in charge (AIC) seated in the rear-facing captain's seat experienced some right leg pain. He was not ejected from the seat and possibly injured his leg as he attempted to catch the PCA.

The ambulance driver complained of lower abdominal pain as a result of the seat belt tensioning on striking the curb. The patient, who was restrained with three cross belts and two shoulder straps (five-point safety system), was uninjured. When interviewed after the accident, he fully attributed the shoulder straps as the reason that he was not injured.

The PCA, driver, and AIC were transported by ambulance and evaluated in the emergency room. All were subsequently discharged with no significant injuries.

Policy review substantiates that seat belts are required at all times while riding in the front of our vehicles and at all times while riding in the back when patient care does not necessitate otherwise.

Drivecam had been installed and was functional on this unit. Review of the accident substantiated the account given by our employees. A description of the other vehicle was provided to local police. Drivecam also revealed that our driver was wearing his seat belt and had an appropriate reaction to the impending collision, preventing further damage or the involvement of other vehicles traveling on the roadway.

This was one of two unrelated accidents experienced within our organization in the same day. A safety debriefing was held the next day with all leadership staff across all divisions. Lessons learned, including a focus on our policy of seat belt use in the rear patient compartment, were discussed and subsequently shared with all staff members.

October 24, 2008 

The Carilion Clinic Life-Guard 11 EC 135 helicopter based out of Carilion New River Valley Medical Center in Christiansburg, VA, was dispatched to Twin County Community Hospital in Galax, VA, to transport a patient to Forsyth Medical Center in Winston-Salem, NC. At the time of the request at 12:45 am, WSI and helicoptor emergency medical services tool weather reports indicated acceptable weather minimums between the two facilities. The flight was accepted.

The first leg of the flight was uneventful. The patient was assessed and prepared for transport and loaded into the aircraft. At the time of liftoff, the pilot advised the CCPT Communications Center that unforecasted weather was noted and that the ceilings were dropping. Approximately 1 minute earlier, the Life-Guard 10 helicopter aborted a flight while in the Roanoke, VA, area because of lowering ceilings. Approximately 2 minutes after liftoff, the Life-Guard 11 pilot decided to abort the flight. The patient was returned to the original sending facility without incident, and ground transportation arrangements were made. The Life-Guard 11 helicopter returned to its base without further incident.

On returning the patient to the original sending facility, the flight crew was advised by the hospital staff that another air medical program had previously turned the flight down for weather. Neither the CCPT Communications Center nor the Life-Guard flight crew had been advised of this weather turndown before requesting Carilion Clinic Life-Guard to transport the patient. The other medical helicopter is visual flight rules only, with night vision goggle (NVG) capabilities. Although the Life-Guard 11 helicopter is instrument flight rules (IFR) capable, this pilot has not yet been certified as IFR. The Life-Guard 11 helicopter is NVG capable.

A debriefing with the medical crew and administration, along with Air Methods pilot representatives, has since been completed. A discussion also took place with the other air medical program, and it was agreed that, effective immediately, all weather turndowns shall be logged into www.weatherturndown.com. CCPT administration is in the process of following up with the sending facility with regard to helicopter shopping.

October 26, 2008 

Hartford Hospital LIFE STAR's (Hartford, CT) LIFE STAR 2 initiated a precautionary landing at Hartford-Brainard Airport (Hartford, CT) after experiencing a significant reduction of power in the number 2 engine. The landing was accomplished without incident, and the PAIP was initiated successfully. The medical crew and patient were transported by ground ambulance to the receiving facility from the airport. After further inspection, our mechanics determined that the number 2 engine needed replacement and the aircraft was placed out of service. The number 2 engine was subsequently replaced.

The weather was clear and not a factor. Air Methods is the vendor.

October 30, 2008 

This incident involves Critical Care Transport (Birmingham, AL). On takeoff from Birmingham airport, the tower believed they spotted smoke coming from one of the Cessna Citation Bravo's engines. They did a fly-by and no smoke was seen; nothing of significance appeared on the aircraft instruments. The aircraft returned to land at Birmingham, and the mechanic performed a thorough inspection but found no problem. The aircraft was returned to service.

The weather was clear and not a factor. LifeGuard Transportation Services is the vendor.

November 3, 2008 

The BK-117 aircraft with STARS (Calgary, AB, Canada) was dispatched on a medevac from Grande Prairie, AB, to High Prairie, AB. Immediately on takeoff from Grande Prairie Airport, AB, the master caution light illuminated, along with the number 1 engine chip caution panel segment. Checklist procedures were carried out, and the engine was shut down. The aircraft returned to Grande Prairie Airport and landed on runway 25 without further incident. The weather was clear and not a factor.

November 10, 2008 

En route to Oregon Health & Science University Hospital from Cottage Grove, Ore, Life Flight Network's (Aurora, OR) Life Flight 5 struck a small duck at approximately 2,500 mean sea level (MSL). The impact area was the aircraft nose. A precautionary landing was executed at the Albany airport. A second Life Flight helicopter was in the air and was immediately diverted to transfer the patient. A thorough inspection revealed no damage to the AS 350 B2. The weather was clear and not a factor. Air Methods is the vendor.

November 13, 2008 

While a team with Benefis Mercy Flight (Great Falls, MT) was returning from a scene call at 10:56 pm, flying 4,200 feet (800 above ground level) approximately 2 km south of a highway and a local Air Force base, the AS 350 B2 was forced to take evasive maneuver for an unannounced military helicopter leaving the military base. At the time, the crew was searching for a third helicopter on their 0800 that Air Traffic Control was tracking and notified to Mercy Flight. The Federal Aviation Administration (FAA) then abruptly announced the presence of the unidentified military aircraft. Looking forward, the crew saw the “huey” less than 1 km away and closing. With visual contact, evasive maneuvers were implemented, and the two aircraft passed within approximately 100 meters of one another. The weather was clear and not a factor. Metro Aviation is the vendor.

Once the two aircraft were safely out of range of one another, the military helicopter questioned air traffic control (ATC) as to why the medical helicopter was within “their” airspace. Further communications were completed once all aircraft completed their missions.

A postflight debriefing was conducted with the lead rotor-wing pilot, the FAA, and military authorities, who confirmed that there is no specific military-controlled airspace within the terminal radar service area (TRSA) of Great Falls and that all aircraft (including military) must announce their presence and operation within the TRSA to ATC.

November 20, 2008 

While responding to an interfacility transport at cruise flight of 2,000 feet MSL, a Vanderbilt LifeFlight (Nashville, TN) team heard an extremely loud explosion. No change in aircraft control or master warning light occurred, and all instruments were normal. Further assessment revealed that the pilot's greenhouse was shattered and the top of the pilot's helmet was covered with bird remains. The BK117B-2 had just passed a rural uncontrolled airport and aborted the flight to land at the airport. The aircraft was put out of service to be inspected by maintenance. The aircraft window is to be replaced.

The weather was clear and not a factor. Air Methods is the vendor.