Concern Network

March 20, 2009 

The pilot for an Air Link at Regional West (Scottsbluff, NE) mission reported an overtemp sensor. The Bell 407 was grounded for inspection. During the inspection, an overspeed event was found. The helicopter was grounded the next day, the engine was replaced, and subsequent maintenance was performed. The weather was clear and not a factor; Med-Trans is the vendor.

April 3, 2009 

On a return night flight from Salt Lake City to Twin Falls, Idaho, Air St. Luke's (Boise, ID) crew encountered low-visibility weather conditions and a simultaneous loss of satellite tracking and communications. Available weather checks before departing Salt Lake International showed an isolated cell over Burley, ID. When the Bell 430 crested a mountain pass, they encountered low-visibility conditions. The pilot, under night vision goggles (NVG) guidance, climbed to 6,100 feet and initiated steps for an instrument landing system approach to Twin Falls, Idaho, but shortly broke out into clear skies. At approximately the same time, Sky Connect satellite tracking and phone communications were lost. Dispatch transitioned tracking to Idaho State Communications Center. There was also a failure of the state microwave tower in the area, so emergency medical services (EMS) radio communication could not be established. Cell phone communication was successfully established within 10 minutes. The Safety Committee is conducting a separate analysis and action plan regarding both the weather encounter and the satellite and radio communications failures. Idaho Helicopters, Inc, is the vendor.

April 3, 2009 

A CCPT Radford Transport Division ALS ambulance with Carilion Clinic Patient Transportation (Roanoke, Va) received a call at 5:09 am for a critical patient transport. Patient was prepared for the 2.5-hour transport without incident to a medical center in Charlottesville, Va. The weather at daybreak was heavy rain and fog.

While driving in emergency mode with red lights and siren activated, the Ford E450 driver noted traffic slowing suddenly. (Later it would be determined that an accident had occurred just ahead of his location on the interstate). There was a tractor trailer in front of the ambulance in the left lane and another similar vehicle in the right lane.

To avoid striking the left-lane truck in a straight-on collision, the driver began braking. Noting an open area on the shoulder of the road, the driver took actions to head in that direction. (It should be noted that, in this area, the shoulder is very wide and flat.) As he transitioned across from the left lane toward the shoulder, the ambulance suffered a loss of traction and began to skid while still in the right lane, striking the rear of the tractor trailer that was in the right lane. This impact caused significant damage to the front of the ambulance and deployed both front airbags.

The attendant in charge (AIC) was seated, belted in the captain's seat, and was uninjured. He first checked the patient, who was still secured to the now displaced stretcher with three cross belts and two shoulder straps (5-point). The AIC then spoke to the front seat passenger, who stated he was OK. The driver stated that he was injured and could not move because of the vehicle damage and the steering wheel against his chest. The front seat passenger, who was belted, was able to extricate himself through the passenger side window without the guidance or advice of the AIC.

The AIC's personal phone was damaged in the impact, and the ambulance's cell phone and radios were inaccessible because of vehicle damage. The AIC was able to obtain the driver's phone to call 9-1-1 for assistance and contact CCPT Communications Center. CCPT Lexington City Contract 911 Division responded to the incident, as did the CCPT Lexington Transport Division. After arrival of several EMS agencies and two fire departments, all four occupants were transported to Carilion Stonewall Jackson Hospital.

The driver was air-lifted later by Carilion Clinic Life-Guard 10 to Carilion Roanoke Memorial Hospital for additional treatment and surgery for evaluation of possible abdominal injury and leg fractures. The patient was evaluated and discharged to continue transport to the original destination hospital. The passenger and AIC were also discharged from the emergency department.

A ground post accident incident plan (PAIP) was activated and ICS structure implemented. Because of the early timing of the incident, most of the administrative team were still at home. The safety officer was closest to the scene and responded first, with the senior director responding to the receiving hospital, and the ground division director arriving later. Remaining management set up an IC structure at the main base to coordinate employee, family, and public relations efforts.

The stretcher came out of the factory-designed bracket and locking system. The AIC describes the stretcher frame rising to his eye level as he was forced into the seat during deceleration and impact. The stretcher landed at a reported 45-degree angle toward the bench seat with the patient still safety secured to the stretcher. During postincident review, it was noted that the stretcher and stretcher locking mechanism were both bent because of the accident. The DriveCam in the ambulance did not record the incident and was found on the windshield, on the roadway, in front of the ambulance. Virginia State Police investigated the incident and did not charge anyone involved in the incident. The ambulance is a total loss.

Immediately after the incident, a HotWash was completed, and on April 6, a full process debrief was completed with a list of what went well and lessons learned. Reinforcement points included: continued focus on restraint use by all occupants in the ambulance at all times, importance of securing all equipment, and importance of use of the five-point harness stretcher system.

April 3, 2009 

A LifeLine Critical Care Transport (Indianapolis, IN) pediatric/neonatal team had just completed a patient mission, and the driver/operator was repositioning the 2005 MedTec/International 4300 ambulance to the program's dedicated parking area. Approximately 1 block from the hospital, a small sport utility vehicle (SUV) traveling the wrong way on a one-way street hit the ambulance head on.

The Indianapolis Metropolitan Police Department officers investigating the crash say the driver of the SUV struck the ambulance at approximately 80 mph. The collision sent a ladder on top of the SUV through the ambulance windshield. The steering wheel stopped the ladder from hitting the driver/operator, who was surrounded by other traffic on the street, which is three lanes wide, one-way northbound. She observed the SUV coming at her, flashed her headlights, and activated her emergency warning lights in an attempt to attract the other driver's attention. She was able to slow the ambulance to “less than 20 mph, and maybe even almost stopped” before impact.

The other traffic beside her allowed no room to maneuver out of the SUV's path. The impact moved the ambulance approximately 9 feet backward from the route of travel. The ambulance sustained moderate damage. Paramedics transported the LifeLine team member to Methodist Hospital with shoulder pain. She was admitted overnight for observation and released the next day.

The SUV driver died at the scene. Police say that driver had hit several newspaper boxes two blocks away before hitting the ambulance. The crash was being investigated by the Fatal Alcohol Crash Team, officers who handle crashes in which drunk driving is suspected. No cause has been released yet.

Take-away points: All of our driver/operators are required to have Emergency Vehicle Operator Course training. In an after-action debrief, our driver/operator advised that this training was helpful in keeping the ambulance in its lane and controlling the deceleration before impact. She was able to self-extricate and attempted to provide care to the SUV driver until other motorists and bystanders intervened. Even though the reposition for parking is only two blocks from the emergency department entrance, mandatory seat belt use clearly helped reduce injury.

April 25, 2009 

On landing approach to the destination hospital, a LifeFlight Toledo (Toledo, OH) pilot noted an unsafe gear indication after gear extension. Emergency gear extension corrected the problem without further incident. Subsequent maintenance inspection revealed damage to the A109E's hydraulic lines.

The weather was clear and not a factor; West Michigan Air Care is the vendor.

April 25, 2009 

A SEARCH Air Medical Service (Sitka, AK) crew launched from Sitka. The Piper Navajo Chieftain pilot noticed that the cowling cover over the left engine was gaping in the front approximately 15 minutes into flight to Hoonah. The pilot returned to Sitka airport without incident, the cowling was secured, and the plane was placed back in service. The weather was clear and not a factor; Harris Aircraft is the vendor.

May 2, 2009 

En route to a receiving hospital after leaving a scene, a STARS (Calgary, Alberta) crew felt and heard a thump as if something had fallen on the floor in the aft cabin. Air medical crew was asked whether something was dropped, and with a negative answer, the BK 117 pilots suspected a bird strike. There were no secondary indications, so the mission was continued to the destination hospital. Both pilots were wearing helmets with the visors down.

Approximately 5 minutes later, while on the long final approach to the hospital, a second small bird struck the copilot windshield, with accompanying splatter. The aircraft landed with no further incident. On inspection of aircraft, no visible damage was found, only “blood and guts” on the windshield and midway along the “red” rotor blade. Engineering was called, and after consultation the aircraft was flown the 2 minutes back to base, where the engineer completed a closer inspection. No damage was found. The weather was clear and not a factor.

May 7, 2009 

On return at night to the University of Michigan Health System, the University of Michigan Survival Flight pilot noticed a noise consistent with a bird strike. On landing, the pilot inspected the BH 430. A bird strike was confirmed, but no damage was noted.

As a precaution, the mechanic on call was informed. The mechanic responded to the base location and inspected the aircraft and, finding no damage, placed the aircraft back in service. All appropriate parties were notified.

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

May 10, 2009 

While an Aero Med Spectrum Health (Grand Rapids, MI) crew was on the scene of a multiple-victim accident with prolonged extrication, a ground ambulance reentered the landing zone (LZ) to assist with patient care needs. The ambulance was initially located well outside the perimeter of the LZ in accordance with our procedures. Because of deterioration in patient status, the ambulance was summoned to the LZ. The rear of the ambulance impacted the tip of one of the Sikorsky S-76C's main rotor blades, which had previously shut down, resulting in damage to the tip cap.

The pilot in command immediately placed the aircraft out of service, and patient care was completed by a short ground transport to the trauma center, using our medical team and local EMS. A new tip cap was installed at the scene by our maintenance personnel, and after a detailed inspection, the aircraft was returned to service within several hours of the event. A review of the event is in progress, and reeducation of scene personnel is planned. The weather was clear and not a factor; the service is its own vendor.

May 15, 2009 

A CALSTAR (Salinas, CA) aircraft and crew departed a LZ, and on climb-out at 1,200 feet above ground level, a seagull hit the pilot side chin bubble, breaking it. The bird did not enter the MD 902 cockpit. The PIC determined that the only damage to the aircraft was the blown-out chin bubble. On briefing the crew, they elected to continue the short flight to the intended destination hospital. The bubble was replaced, and the aircraft was inspected and returned to service. The weather was clear and not a factor.

May 16, 2009 

While flying a patient from Lamar to Denver, CO, a flight crew from Flight for Life Colorado (Denver, CO) encountered ducks near the town of Simla. One duck struck the nose of the AS 350 B3 just above the pilot side chin bubble, bending the plexiglas back sufficiently to enter the cockpit. Debris trailed back through the cabin to the back wall. A second duck struck the left side windscreen and traveled aft along the side of the helicopter but did not penetrate into the cabin.

The pilot landed in a field west of Simla, just north of Highway 24. Another Flight for Life Colorado helicopter was activated. The transport was completed with no deleterious effect.

All three crewmembers were wearing helmets with their visors down. There were no injuries to the crew or the patient from duck debris. The pilot was able to land the aircraft quickly after the impact, aided by NVGs. The Communications Center staff responded to the initial reports of the duck strike and emergency landing by activating the PAIP and ensuring rapid assistance to the crew.

A ferry permit was obtained on May 18, and the aircraft was flown from Simla to Air Methods in Englewood, CO. Repairs were effected quickly, and the aircraft returned to service on May 21. Air Methods is the vendor.

May 17, 2009 

At approximately 1:10 am, North Colorado Med Evac 1 (Greeley, CO) was on a patient transport from North Colorado Medical Center in Greeley to Swedish Hospital in Englewood, CO. The Bell 407 experienced a bird strike over Denver. The pigeon struck the pilot's windscreen in the upper right corner, breaking the plexiglas. The bird and debris entered the cockpit, striking the pilot in the helmet/visor. The pilot's visor was down, and he was not injured by the impact.

The pilot reduced airspeed, communicated the situation and his intentions to the onboard medical crewmembers, and made an uneventful precautionary landing at a local airport. Dispatch was advised of the bird strike, and the PAIP was implemented immediately as per protocol. A ground ambulance was dispatched, and the patient was transported to the receiving hospital without further incident.

A backup helicopter was dispatched to provide coverage for the program, and the flight team was transported back to their base. The weather was clear and not a factor; Med Trans is the vendor.

June 10, 2009 

Mayo Clinic Medical Transport (Rochester, MN) was en route with a patient, two medical crewmembers, and pilot from Decorah, Iowa, to Rochester, Minn. Approximately 10 minutes into the patient transport leg, the low oil pressure light for the BK 117 C1's engine #2 illuminated. The pilot confirmed the low oil pressure on the corresponding gauge for engine #2 and immediately notified the crew that the emergency checklist procedure was being activated and followed, and the engine was shut down. The pilot then located the closest airport, Fillmore County Airport, which has hard surface runways that are unlighted. Using NVGs, the pilot and crew successfully executed the single-engine run-on landing and shut the aircraft down. During the landing, the medical crew confirmed oil accumulating on the rear clamshell door and noted the smell of hot oil.

On landing, the patient and medical crew were met by a local basic life support ambulance crew, which provided transport of the patient and Mayo One crew to the receiving hospital. Patient transport was completed without impact to the patient. The weather was clear and not a factor; Omniflight Helicopters Inc, is the vendor.

The PAIP plan precautionary landing portion was activated and leadership notified before landing. After the event, all crewmembers were debriefed. Mayo One team members from the other Mayo One base's crewmembers were notified of the situation and apprised of the crew and aircraft status. The Mayo One team moved medical equipment and supplies into our backup aircraft and placed the base into service. The event has been reviewed by the Mayo Clinic Medical Transport Safety Committee.

The aircraft was placed out of service, and maintenance technicians responded to the aircraft and performed an inspection. The source of the oil leak is suspected to have come from the midsection of the #2 engine. A replacement engine was ordered and the aircraft returned to service after completing associated details. The base remained in service with backup aircraft.