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Subject: NTSB in Washington, DC and the recent spate of EMS fatalities
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marcsalUser is Offline


02/01/2005 7:52 AM  
All: Just thought I'd give you a sort of personal update on what's been going on over here down on the Potomac River near Prohibited area 56 (White House). A few days ago, I had a nice conversation with a good friend (and commercially rated instrument pilot) who is a supervisor for Human Performance at the NTSB here in DC named Dr. Evan Byrne. Dr. Byrne and the NTSB have (quietly) been conducting field studies with regards to the alarmingly high spate of EMS accidents since before the South Carolina EMS fatality of a few months ago. With the recent EMS fatality of the EC-135 that crashed into the Potomac river just within DC Reagan International airspace, the NTSB has been accelerating their efforts. During our discussion, I mentioned to Dr. Byrne that the "Climate" that existed back in the dark days of the mid eighties (remember those dismal times?) and the FAA's assertion that pilot's were literally "Killing themselves because of White Knight syndrome" (Gore commission in 1987) just didn't hold water and that the NTSB would never reach a satisfactory conclusion unless they rectified the existing competitive corporate climate by holding senior leadership accountable (similar to how the Military addresses the problem as one of Command or lack of Command presence: breakdown in senior leadership...hold the most senior leader accountable right down to the lowest airman, soldier, sailor, or employee) for the actions of their subordinates. We talked at length about the existing competitive nature of the business, subtle pressures and undue influences on aircrews from outside sources, aircraft restrictions/limitations, weather limitations, and the true lack of documented training or non-existant training for non aviation personnel filling aviation leadership or managerial positions (I cited my own experiences and current situation as a case in point). We also discussed training programs that are readily available but I cited that a majority of personnel in leadership or managerial roles did not ascribe to this type of training, did not feel it was necessary, or dismissed it as too cost prohibitive. I played a video tape of the old "20/20" and "60 Minutes" interviews with pilots, technicians, managers, and (then) Senator Al Gore as they discussed the eighties accident rate among EMS carriers. When it concluded, I asked Dr. Byrne what were his thoughts...he confessed that very little had occurred in the realm of education and prevention in over 18 years since the Gore Commission released it''s findings. I asked Dr. Byrne to please consider a public forum where actual testimony from pilots, technicians, and aircrew is given...where they can talk as opposed to having the NTSB host groups that are more prone to their own agenda thus flooding the ranks with CEO's, CFO's, Hospital Administrators, and the like. I suggested a good across the board section of the industry would be in order but that the Fed needed to HOLD THOSE IN LEADERSHIP POSITIONS ACCOUNTABLE and not pay anymore lip service. With this im mind, I stated that the Fed also had to enforce that the Pilot-In-Command needs to know that He/She is supported and that the PIC does not fly from the back seat...in other words the PIC needs to be put back in charge of his/her aircraft along with the responsibilityu for it's contents (not to dismiss CRM by no means) and that a Program manager, Chief Flight Nurse, or other influence is legally, morally, technically, in violation of the FAR's and will be dealt with accordingly, no if's and's or but's. In concluding I advised Dr. Byrne that should the NTSB decide to have an open public forum, there would be such an overwhelming request from those of us "In the trenches" to participate, the NTSB would not be able to honor every request. Dr. Byrne is taking my information to his superiors...I'll keep you posted as things happen. FYI...I'l be meeting with the folks from ATC at Washington Reagan INTL on the 17th of February for a meeting on some proposed changes to the airspace around the Potomac...I have advised my superiors and they'll also be sending some reps. to the meeting. Regards, Marc P. Cournoyer
EJStock44User is Offline


02/01/2005 11:06 AM  
Marc, Great post! It’s been my contention for some time that decisions that are made at the different levels of management affect the decisions of the folks at the end user level. That would certainly include the medical as well as the aviation management. In traveling around and teaching CRM and other classes I have rarely seen any management types attending the training. Understanding that CRM has its place, it is not going to solve the problems we are currently experiencing in our industry. It seems that some expect it to accomplish more then it was designed to do. Holding the management responsible, and providing training that would emphasize that we are involved in an AVIATION OPERATION with a medical mission would be a good start. Unfortunately, there is no one problem that can be identified as the single cause of accidents. It seems that there are tendrils that extend into all aspects of our business. Hiring practices, training, equipment /technology, wx minimums, policy and procedures and dealing with competition could use some fresh and innovative thinking. As an industry we need to admit that the pilots are not solely responsible, but are a product of the culture. We also need to admit that subtle pressures do exist and work to identify, and eliminate them. The need to base aviation decisions on purely aviation factors is paramount. I believe that unless we experience a paradigm shift, and address these issues we will continue to experience high accidents rates.
macevacUser is Offline
JH Newbie
JH Newbie

02/02/2005 7:06 PM  
Although I agree with most of this fine post, I do not agree that the White Knight syndrome is gone as this post seems to say. Managers and CEOs need to be accountable no doubt, but a small percentage of the pilot and medical group still believe in taking risks. Management is perhaps not making it clear enough to them that risk taking is NOT ACCEPTABLE or they are tacitly allowing a certain amount of risk taking in their culture. I have been a member of just about every survey, committe, meeting etc. that has had anything to do with the EMS helicopter accident dillema since 1993 and studied most of the recent accidents in some depth. Many are simply caused by poor pilot decision making (exclusive of the corporate or local climate) and apparently influenced by the "white knight" or hero mentality. Having flown EMS in the Civilian world in about five different programs for a good long time and having served as an EMS aviation Chief Pilot, I continue to see accidents wherein external and internal pressures seem to drive pilots into terrain on dark nights and/or through adverse weather. Is that the CEO's or competition's fault? I was a manager in the safest corporate culture I have ever observed and we still had an accident when a pilot went beyond his limits into hazardous conditions. It was as baffling to me then as are some of the recent and past accidents I have studied. I believe, as this post has suggested, that leadership must be accountable but this is not an "either-or" problem...it requires a multi-focal approach not limited to the evils of competition and corporate dealing alone. There are many factors that must not be ignored--local safety culture and values, pilot and crew training, CRM, aircraft and equipment, FAA (or some adult) oversight and medical management in aviation decision-making, more appropriate weather minimums, better weather forecasting, GPS, IFR and NVG. Thanks for letting me vent! Ed MacDonald Safety Representative NEMSPA
marcsalUser is Offline


02/03/2005 5:48 AM  
Ed: I too do not believe that the "White Knight" pilot (or medical crewmember or Hospital staff member) is gone either. I DO believe that when the FAA focused on this as they did back in the 80's, they were "Short sighted" in their reports to Senator Gore and his colleagues and they failed to recognize other facets of the problem. Yes, I am sure there are many instances where a pilot has made critical (and fatal) decisions based on patient needs, whther it came from within or from externally driven sources. I fully agree that the inherent problems that plague our profession are multi-layered and interwoven. A good friend who is a flight nurse/CRM instructor always uses the line "Good programs have killed people" when addressing new hires during their orientation...he speaks from experience. In my conversation with the NTSB, I tried to stress that both the NTSB and the FAA need to address the problem at the top (as does the Military when command breaks down) all the way on down to it's lowest common thread...just saying "It's the pilots' fault" is from a legal standpoint probably true but not fully accurate...one must dig a lot deeper into the culture that caused the problem to manifest to begin with, something that both the NTSB and the FAA repeatedly have failed to do as have we as an industry. I am fully aware of your past and present labors in this field as I read many of your reports over the years. I am honored that you took the time to rspond to my post. I am enclosing Dr. Byrne's address and phone number should you want to communicate directly with him in the near future. Respectfully, Marc cc: Evan Byrne, Ph.D Chief, Human Performance Division Office of Aviation safety (AS-60) 490 L'Enfant Plaza East, SW Washington, DC 20594-2000 (202) 314-6352 (office)
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Forums > JH Alternate Forum > General Helicopter Discussion > NTSB in Washington, DC and the recent spate of EMS fatalities

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