Management at Survival Flight, which operated the January EMS flight that crashed in Ohio killing all three personnel aboard, pressured pilots and crews to fly in inclement weather, often insisting they take risky flights other operators had turned down, according to a National Transportation Safety Board (NTSB) report on the human factors that led to the fatal accident.
The report, dated Sept. 20, is based on interviews with current and former employees of Viking Aviation, which under the name Survival Flight operated the fatal Jan. 29 flight in Ohio. On that night, the Survival Flight pilot accepted a 69-mile flight between two hospitals that had previously been turned down by two other HEMS operators.
About 20 minutes after takeoff, the Bell 407 crashed into hilly, forested terrain about four miles northeast of Zaleski, Ohio. The pilot, flight nurse and flight paramedic were killed.
As outlined in the NTSB report, the helicopter wreckage was located on a tree-covered hill and exhibited significant fragmentation. The certificated commercial pilot, flight nurse, and flight paramedic were fatally injured in the crash. Ohio State Highway Patrol Photo
The NTSB's Operational Factors and Human Performance report, published Sept. 20 and released when the FAA opened its docket on Nov. 19, details interviews with current and former pilots at Survival Flight, operated by Viking Aviation.
The FAA's docket for the case includes 1,025 pages of interviews. Employees reported incidents of being cussed at by management and chief pilots at various bases for not accepting flights, pressure from non-aviation management to make unrealistic flight quotas and inability to take bases out of service because of wind, weather or maintenance concerns.
Current Survival Flight employees, including pilots and medical staff have texted former employees that they are "scared to fly," according to the report. A flight nurse interviewed for the report said the company's aviation staff were generally risk averse and safety conscious but were pressured by management to make unsafe decisions on whether to accept flights.
Employees describe a culture where pilots and crews were "cussed at," "berated" and threatened with firing for refusing flights because of legitimate safety reasons.
Through a process dubbed "reverse helicopter shopping" managers and operations center employees at Survival Flight would seek flight requests that other operators had turned down as too risky, then passed them onto aviation staff and pressured them to accept, according to the report.
Survival Flight, in written answers provided to Vertical, categorically disagreed with many of the statements former employees made to NTSB investigators.
Specifically, the company denies "that crew members were yelled at for declining flights because of safety concerns," Survival Flight spokesman Ryan Stubenrauch told Vertical in an email.
"To the contrary, we train, remind, and require each pilot and nurse in the crew that they have both the power and the responsibility to reject any flight if they feel something could go wrong," Stubenrauch wrote. "Every single flight request that we get can only take off if all three crew members and the operations control manager okay it. If any one of those four people have doubts, the flight doesn't take off."
Interviews with NTSB investigators did shed light on some "human resources problems and communication issues between some employees," Stubenrauch said. "We investigated those issues when we became aware of them and required additional training in an effort to streamline and improve communication between staff."
The NTSB's report is preliminary, yet HEMS personnel who spoke to Vertical were uniformly shocked at the lax safety culture it details and the FAA's failure to recognize the problem before it cost three people their lives.
"I've heard from many of my colleagues . . . that reading that report is the worst thing they've ever read in terms of the operational culture of the program," Dr. Bill Hinckley, medical director and flight physician at the University of Cincinnati's Air Care and Mobile Care, told Vertical in an interview.
"It is extremely frustrating and disheartening. We work so hard to maximize our aviation capability and our clinical capability. ... When these sorts of things happen, the majority of the lay public and, in fact, the majority of the medical public, believe that a helicopter is a helicopter and a HEMS program is a HEMS program and they're all the same."
When considering flight requests, HEMS best practices typically include the rule "all to go, one to say no," meaning that the pilot, flight nurse and EMT or physician should all agree that a flight is safe and each has veto power.
"Even if the pilot accepts a flight, I as the flight doc, have the right and responsibility if I'm not comfortable to say 'No,'" Hinckley said. "So does my partner the flight nurse and so does the communication specialist and so does the person sitting in the control center."
Pictured is the accident aircraft, with registration number "N191SF." The helicopter was registered to and operated by Viking Aviation, doing business as Survival Flight, as a visual flight rules air medical flight under the provisions of 14 Code of Federal Regulations part 135 when the accident occurred. Jonathan Quilter Photo
According to the NTSB report, at Survival Flight that system of redundant checks broke down when flight decisions were effectively ceded to non-aviation management.
Dr. Craig Bates, medical director of Metro Life Flight and attending physician at MetroHealth Department of Emergency Medicine in Cleveland, Ohio, was disturbed by aspects of the report such as the reverse helicopter shopping, but is concerned the alarming allegations will detract from opportunities presented by the report for HEMS operators to enhance their own safety. The NTSB and FAA should focus on the allegations while the HEMS community focuses on "extracting lessons" from the tragedy and what led to it.
"This crash happened near our service area and people we care about are involved in the program. It's important to emphasize this release doesn't contain any conclusions, but rather interim information from NTSB's fact-finding process," Bates wrote in an email to Vertical. "While these documents don't determine blame for the specific crash, they are a great tool to help assess and improve the safety culture and processes in each of our own transport programs. There are always opportunities to improve."
"The quest to optimize quality and safety - whether aviation or medical - is a constant team effort," Bates added. "This includes working even harder to reduce real or perceived pressures to initiate and/or complete transports and further reducing the risks inherent in weather shopping."
'Reverse Helicopter Shopping'
Helicopter shopping is a practice in which a medical facility contacts multiple helicopter operators until one is found that will accept a flight request.
Michael Benton, a HEMS pilot and aviation safety consultant, said it is not unusual for hospital staff to call multiple providers because their first priority is patient wellbeing. Air ambulance pilots and HEMS personnel, conversely, are expected to prioritize flight safety and risk assessment - previous flight turndowns included - instead of a patient's condition.
"It's normal for them to call multiple providers," Benton said. "It becomes negative when you are not sharing the fact that you called two or three others and what the results were."
On Jan. 29, Holzer Meigs Hospital first contacted MedFlight, its regular HEMS provider, but was refused due to weather concerns. Hospital personnel called at least one other HEMS provider, which also refused the flight, before Survival Flight accepted.
While the hospital was shopping for a helicopter to transport a patient, Survival Flight was sometimes shopping for flights that other operators refused, a process called "reverse helicopter shopping," according to the report. Citing employee concerns, the NTSB indicates that personnel in the Survival Flight operational control center (OCC) were using the weatherturndown.com website to find helicopter air ambulance flight requests refused by rival operators due to weather concerns.
"One pilot noted that anytime he received a flight request for a flight outside of their normal program area he suspected that OCC was using weatherturndown.com to find flights," the report says. "Another pilot expressed similar suspicions but noted that this practice by OCC would not affect how flight crews at his base would approach a flight request."
Survival Flight denies it ever authorized or condoned reverse helicopter shopping, though the company's operations system pulls data from multiple sources, including weatherturndown.com, Stubenrauch said. Data from that website, however, was not used to schedule the Jan. 29 accident flight, he said.
"Only a small handful of flights out of the thousands and thousands of flights in our company's history have ever come from data obtained through that website," Stubenrauch said. "On those rare few occasions, we knew that the other company purportedly turning down the flight for weather was really turning down the flight because of a maintenance issue."
Prior to the crash, the Survival Flight helicopter was on its way from Mount Carmel Grove City Hospital to pick up a patient at another hospital. Survival Flight Photo
Hinckley said he had never heard of reverse helicopter shopping in his entire career and that the tactic exists at all is a sign that major HEMS regulatory changes are due to incentivize safety over profit.
"There needs to be universal condemnation of both helicopter shopping and, especially, reverse helicopter shopping," he said.
Survival Flight has since prohibited its dispatchers from "anything similar to 'reverse helicopter shopping' even if we have information suggesting the flight was turned down for something other than weather," Stubenrauch said.
Pressured to fly
One Survival Flight pilot quoted in the NTSB report describes "an awful push to get numbers" in an "environment that felt like competition." The pilot told the NTSB that the company's vice president of EMS set a 150-flight per-month flight volume quota where the pilot's realistic estimate was between 30 and 35 flights per month. In another case, management promised bases a new massage chair if they flew 30 flights in one calendar month.
"There were numerous company personnel who witnessed people in management, including the chief pilot, pressuring pilots to accept flights," the report says.
Benton said the reported pressure Survival Flight management put on pilots to fly was "a big eye opener."
"If it's true what they said about the chief [pilot] and those guys, it's pretty shocking," he said.
One pilot described a situation where another pilot reported to the [operational control manager] that he was concerned he was too tired to take another flight after having flown three, but the chief pilot serving as the OCM at the time convinced the pilot to accept the flight.
The pilot was told to "maybe drink a cup of coffee before you go ... and try to get it done," according to the report.
Numerous pilots and medical personnel witnessed management being "reprimanded or challenged for declining a flight," according to the report. When some flights were declined, one medical crew told the NTSB, "the chief pilot of the company... would call within about 10 minutes and would cuss out our pilots and belittle them."
Survival Flight outright denies that any pressure was placed on any of its flight crews to fly in unsafe conditions. Before any flight takes off, the company requires four people to give the go-ahead.
"All three crew members and our operational control manager have the ability to turn down or cancel any flight at any time if they have a concern about fatigue, weather, or any other potential danger," Stubenrauch said.
"Our bases go out of service for weather or maintenance every day," he added. "Each year, Survival Flight turns down thousands of flights for weather, maintenance, or other reasons. In fact, one out of every four flight requests we get are turned down for weather alone."
Survival Flight's CEO Responds
On Nov. 25, Survival Flight CEO Chris Millard sent a "Thanksgiving Message" to employees that amounted to a defense of the company against the NTSB report wrapped in a holiday missive. It created a firestorm when posted to a HEMS Facebook group's message board.
"Please join me in remembering the fallen and keeping their families in our thoughts and prayers through this season," he writes before slamming the NTSB report as "largely opinion that was collected from former employees who, for one reason or another, were disgruntled when they left."
"To show the points that the NSTB were trying to make, they largely used the comments of those who have left us to insert their own agenda and to try and hurt us," Millard wrote.
Millard said the NTSB is reviewing information on the accident aircraft flight data recorder and is "confident that once they get a closer look at this information, the cause of the crash will be nothing related to weather or anything else that they have speculated on to date, and all of this noise that is out there regarding our operations will all be proven to be untrue and unrelated to the cause."
He followed that up with another email to employees meant "to ensure that everyone once again understands our company's rules protecting our safety, including every member of our crew's ability and responsibility to turn down a flight."
"From day one at Survival Flight, it has been an iron clad rule that everyone have the right to turn down a flight for any reason," Millard wrote. "I also expect and want you to turn down a flight if you feel it's the right thing to do."
Survival Flight has denied "that crew members were yelled at for declining flights because of safety concerns." Sheldon Cohen Photo
Stubenrauch emphasized that the NTSB's report is preliminary and does not make any official findings. He was hired to speak for the company as the investigation unfolds toward a final report. The company recently held a two-day safety stand down at its Ohio bases to emphasize safety. It also has hired an independent aviation expert to perform a "comprehensive evaluation of every policy, procedure and employee at our Ohio bases during that time and will implement any recommendations," Stubenrauch said.
Outcomes and Opportunities
The NTSB's investigation is not final and does not assign blame or name a cause for the accident. Neither has the FAA made any determination of what caused the accident, who is to blame or what new rules and regulations should result.
Benton did not think major regulatory changes would result from the investigation, but said the accident has stirred up more passion for safety awareness since the fiery 2015 Flight for Life helicopter crash in Frisco, Colorado, that resulted in requirements that certain helicopters be outfitted with crash-resistant fuel systems.
"I think one positive thing that's going to come from this ... I've never seen an accident report generate so much discussion," Benton said. "I don't think you're going to see regulation changes that come from just one accident, but it's definitely going to bring it to the forefront."
Bates was more measured in his assessment of the report, but encouraged the NTSB and FAA to extract as many lessons as possible from the incident and subsequent investigation to boost HEMS safety.
"A big reason why the NTSB releases these documents is because they are an invaluable tool in enhancing safety in our own programs," Bates said. "I sincerely hope that the FAA will incorporate any eventual NTSB findings into improved oversight procedures. This would ensure any lessons learned would benefit a broader population so future air medical crews and patients will be safer."
Ingen kommentarer:
Legg inn en kommentar
Merk: Bare medlemmer av denne bloggen kan legge inn en kommentar.