RE: Cockpit Curtain = Bad? (long post)

[Ken Lawson-Williams <Macgyver@FlightMedicMail.com>]

A new topic for intelligent debate. Skip if not interested or not willing/unable to open your mind to different ways of doing things. Private replies fine.


Recently Jeff Brosius postedin the affirmative, and Bob Carnevale replied in the negative to the concept of pilot awareness of medical condition in response to the following:

>I'm not entirely certain that being 'isolated' is always a good thing.  I 
>can see the argument that being 'isolated' removes the emotional aspect 
>(i.e. "For an adult, I'd probably not fly in this weather, but since it is a 
>kid... yeah, let's go... we should be OK, I think." no longer comes into 
>play.)  However, knowing the level of criticality of the patient might, 
>stressed MIGHT, be an important factor in decision making.  Ground crews, as 
>you well know, use the level of criticality in deciding to utilize 
>lights/sirens to get to the hospital.  Pilots could utilize knowledge of 
>acuity to say "Nope... too dangerous."  


Desite the opinions of many in the industry, I tend to agree with the CRM concept being fully extended to the medical crew - with the corollary that information flow and situational awareness be much more complete in both directions. Maybe it is the difference between fixed wing and rotary... So this may not be necessary for every program, but it apparently is in the fixed wing community in Canada. So, consider the following:


>From the Canadian Transportation Safety Board Report Number A94Q0182, 
24 September 1994 "4.1.4 MEDEVAC Accidents

A disproportionate number of the CFIT accidents currently being studied occurred on MEDEVAC flights, most of them during dark nights. When CFIT MEDEVAC accidents have occurred, the circumstances were frequently such that the flight crew was attempting the flight with a sense of urgency; THIS URGENCY, WHICH COMPELLED THE CREW TO BYPASS THE USUAL SAFEGUARDS TO EXPEDITE THE FLIGHT MAY HAVE BEEN MORE PERCIEVED THAN REAL. (my empahsis) Most CFIT and VFR-into-IMC MEDEVAC accidents occur in a self-dispatch environment, without the first level of planning and monitoring that an effective dispatcher affords. 

Between 1976 and 1994, there were 38 occurrences involving aircraft engaged in air ambulance or medical evacuation operations. Fifteen of these accidents took place in Canada's designated North. Helicopters were involved in eight of the accidents. Twenty-one of the MEDEVAC accidents occurred during VFR flights, and 18 occurred during dark nights (i.e., notwithstanding reported flight visibility conditions, the absence of ambient lighting, either from surrounding built-up areas or from the moon, created extra problems for conducting flight by outside visual reference). Twelve of the 38 MEDEVAC accidents were CFIT accidents, 10 of which occurred at night.

The TSB's Confidential Aviation Safety Reporting Program has received 17 reports on MEDEVAC operations since 1987. Some of these reports made direct reference to pilots' perceived sense of urgency with respect to MEDEVAC operations. IN SITUATIONS WHERE THE CONDITIONS ARE KNOWN TO BE INADEQUATE FOR THE INTENDED FLIGHT, CREWS FREQUENTLY ATTEMPT THE FLIGHT ANYWAY, WITH THE HUMANITARIAN OBJECTIVE TO SAVE LIVES. (my emphasis)

Confidential reporters also confirmed that the absence of any positive operational control over their flights had an impact, in that it led to a risk-taking attitude under the perceived pressure of the medical emergency. As the National Transportation Safety Board (NTSB) study cited earlier in this report suggests, a strong managerial structure is required to support pilot decision making in the working environment of MEDEVAC operations."


Since then I have found 4 published CTSB reports, and personally know of another 3 fixed wing writeoff's and 1 rotary accident, as well as 8 reportable incidents in Alberta/NWT alone. This adds up to AT LEAST 37 fixed wing accidents, 9 rotary accidents, and 25 reportable incidents in 25 years in a country with 10% of the US population, and far less MEDEVAC flights per capita (due to the scarcity of rotary operations). 
A huge proportion of these accidents are classified as "controlled flight into terrain". If you look at the Paramedic Association of Canada Honor Roll (LODD memorials) at www.paramedic.ca/document/Benevolent/benevolent-honor.html
you will find that the deaths from aviation accidents outnumber ground accidents by roughly 3:1 (and that does not include the aircrew killed as well) 

What comes out when reading many of the reports that, in the absence of any medical knowledge, the pilots ASSUMED that the patient was critical. So in other words, by denying them this piece of information, they pre-set the limits of the personal envelope that they would accept flights within on the "high" side of safe. So lets's try something else. A two stage system. The Captain proceedes as normal - in a vacuum and assuming the patient is critical (otherwise why elso would a flight be authorised? Many reasons actually, not all by any means time critical...)

A) Unsafe - flight scrubbed.
B) "Safe" - advises medical crew that the flight is a go. 

At this point, lets introduce a change on the process. A Preflight Briefing where information is shared. The flight crew shares weather information with the medical crew, they in turn share patient information with the flight crew. Remember, this is AFTER the pilot has made his 'blind' decision to accept the flight.

So now it transpiresd that this is a routine interfacility flight for a consult, or even an emergent trip for services not available at the sending facility (or in the Canadian North: nursing station = scene call in many respects) but one that can wait an hour or two without great risk to the patient. And furthur suppose that the weather is marginal.

Now the flight crew, knowing the trip can be postponed to wait for weather without jeopardising the patient has the opportuniity to reassess the "Go" decision. so:

B) Still go - still safe / low risk
C) Scrubbed as marginal weather which could have been assessed either way. 

In other words, the envelope is redrawn back to where it would be for an air taxi/charter flight as opposed to a MEDEVAC flight, in which case the captain would have never accepted the trip as the "Benefit" side of the equation (that he had simply assumed was there as it was a MEDEVAC flight) in reality wasn't.

Of course if the weather is not marginal, but good, the flight will go anyway, as there is minimal risk. Not really all that revolutionary - but I have been roundly critisised in the past for suggesting flight crews EVER be allowed to know what transpires in the medic world. 

In the Yukon, the fixed wing vendor for the territory has obtained ISO 9002 certification. This required the same sort of operational and proceedural/documentation review that CAATS requires (but only on the aviation side). One of the primary SOP's is an assessment of the CFIT risk at the destination - as well as the alternate. (Controlled Flight Into Terrain). The weather factors into their assessment such that if the weather is good the additional risk (over the normal level for that airstrip) is generally low, if bad generally too high (there is a cut off line which Captains cannot exceed). 

As I understand it from discussions with staff, this has removed the pressure of different 'styles' and experience of various captains that used to result in (sometimes erroneous) conclusions that "so-and-so would have taken the trip", or "if I don't then I will seem less capable a pilot" etc. The captain can obvioulsy still cancel a flight even when the CFIT threshold is not exceeded, and they do, but it acts as a second-level safety.

The medical crew also assesses the benefits/medical risks of the flight and no flight situations. So after the CFIT based decision is announced, they can state the benefits of taking the flight. If there is no significant risk medically of delaying, or no significant benefit to taking the flight now (vs for example in a few hours when it is daylight) then a high but sub-threshold CFIT may not be justified so the flight is cancelled. No longer a case of medical crew wanting to get out of the flight or flight crew feeling pressured to accept etc. but a cancellation due to inadequate risk/benefit.

Remember that here a fixed wing flight may be the only option, so often trips are BLS or appointment/consult. Many more are flown simply as ground times of 4 hrs or more by gravel road are not great for patients (especially in the first responder level ground ambulances available nost places). Helicopters do not get much use as strips exist in virtually all communities and FW are not as affected by weather extremes and mountain considerations.

Having said that The presence of a GPWS on one of  the aircraft in an Alberta program was initially just because it was in the avionics suite when the aircraft was assigned to Medevac duty, but has already proven highly usefull and resulted in several approaches being revised for nighttime/mountain MEDEVAC flights (these are minimally lit isolated "black hole" strips whose approaches while legal, may involve a dogleg to aviod a peak intersecting the flight path on approach or climbout, or have only 300-500 feet of clearance vertically/1/8 mile horizontally from terrain). In the past the Transportation Safety Board had critised vendors from removing such safety equipment from aircraft once dedicated to MEDEVAC use (it is not required by the regs) so it was left onboard.

One strip that is commonly used was flown by an experienced pilot in daylight using the new aircraft, and during the approach he recieved not only multiple "minimum" and "terrain" but also two "pull up" warnings while very carefully following the published approach exctly with confirmed altimeter settings from the ground. Needless to say this level of accuracy is not always available at night (no "actuals" from ground, wind shear and storm effects in the mountains, cross winds, no visual references, "black hole" effect etc). 

So now a company approach plate has been developed and a new approach designed that has far greater clearances. Previously, night time and even daytime poor (let alone bad) weather trips to this airport would cause a lot of apprehension in medical crews  due to tree-strikes on approach a year or so ago by another aircraft in the same company on a charter flight co-incidentally using a MEDEVAC pilot. I have been told there has been at least one outright refusal to board the aircraft (citing the Workers Compensation Board right to refuse dangerouus work until the danger has been rectified - which also forbids others from undertaking the same work unless concern has been resolved).

A different solution, but addresses the same problem. Pilots will accept flights with marginal weather even not knowing the patient status because:
1) The MEDEVAC was called thus it must be serious
2) Peer pressure
3) Job/promotion security (not wanting to be seen as lacking skill or confidence)
4) Corporate culture at odds with corporate policy (ie: oficially captain can cancel but those that do get "flagged" as the vendor loses revenue)
5) Mindset that they can always shoot an approach, and if the weather is still poor on arrival, cancel and proceed to an alternate - this way the vendor gets paid. Unfortunately this results in no initiation of other travel arrangements so when the flight is diverted (medical crew not always notified officially untill back above 10,000 feet and refiled so sometimes 5-8 minutes later), it all starts over agin. A huge delay. System problem...

As an aside, should not our flight crews also not be advised of any risks that the patient brings to them? such as airborne transmissable diseases, extreme weights (throwing off standard weight and balance or even total weight/fuel available calculations), or psychosis? Do we do that routinely - or treat them as taxi drivers? I have seen both in different systems. 

Up here in an accident inquiry report by the TRansport Safety Board Transport Canada has held (on the advice of Alberta Health) that Medical crew are not flight crew. The report tends to be impartial on the wisdom of this. But in any case no duty time limitations, no crew rest requirements, no requirement for aircraft orientation or safety training etc. are required of medical staff. Saves the provincial Government's that pay for MEDEVAC's (actually their contractors, but thus contracts cost less and thus transports less) a lot of money but contributes to poor to non-existant CRM. 

One company that treated medical staff as 'Medical Flight Attendants' and gave them the same responsibilities and required safety training required of commercial flight attendants was slammed in an accident investigation because these staff 'technically' were not Flight Crew under the Candaian Aviation Regulations and thus should not have been allowed to give the passenger a safety briefing.  

I could go on about reasons why poor decisions are being made, but systems design in many places contributes hugely to the decision making process and every system is different. But in all systems, good communication and empowering all on board to non-judgementally cancel a mission is going to result in increased safety. Not including each other in the decision making process is tantamount to saying that we do not trust their judgement. The same people we then trust with the lives of everyone on board. 


A properly sequenced and structured method of increasing the information flow and situation awareness of all involved in the flight that is designed to inherently reduce the risk of poor decisions and promote teamwork I find hard to believe will increase accidents...


Awaiting the deluge of dissent from rotor types...

Ken Lawson-Williams, CD
CCEMT-P/WMT/Student Nurse
Canadian Air Force Reserve CRM facilitator/aircrew survival instructor

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