Posted 209 days ago ago by Admin
As a CRM facilitator it’s rewarding when I receive CRM success stories from folks who have a good story to tell. I have two stories to share in this issue, the first from flight paramedic, Rhett Draehn, who is the program safety manager at Careflight in Dallas and took my CRM instructor’s course several years ago. He wrote:
I wanted to share with you an email I received last night from one of our flight medics the day after I hosted a virtual CRM class. My intentions were to hold the classes live but due to the pandemic and deadlines closing in, I had to change the class structure and do it online because I decided that putting this information out virtually was far more important than delaying any longer. I am passing this on to you because I want you to know that your work and dedication to crew safety continues to have a ripple effect in the industry improving our decision making. The information and structure of the class was derived from your CRM Instructor course so I feel that some credit is owed to you. This crew recognized all of the little errors that were stacking up against them, none of which were singularly a deal breaker, but combined as an error chain definitely took their attention away from more important items. Here is the excerpt from the email I received:
“Hey Man, I just wanted to say great job on the AMRM class. I was on the online one yesterday. You kept my attention and I didn't find myself drifting away from the class like we all do on other WebEx style meetings and stuff.
“I wanted to let you know that we definitely put the knowledge to use. Tonight we had a shift-change flight. Mike was just coming in as night pilot. He’s been out for 3 weeks and this was his first night back. We were dispatched on a scene call in an unfamiliar area of Oklahoma. He had to rush to get out and got a little flustered with the NVG goggles and coordinates and then had a miss-start. Once in the air we began having radio problems, map coordinate problems, and our ground contact was wrong. The pilot couldn't transmit from his radio to anyone. Brandon was actually first to speak up, only beating myself and Mike by a split second. We aborted the flight no questions asked. I utilized our back radio to communicate to our communications center and we returned to base with no problem. We broke that link in the chain. Once safely on the ground we debriefed and figured out the radio problem. Then we remained out of service until we all briefed and debriefed and were comfortable with what had transpired.”
Randy, I wrote to say thanks for your dedication to safety and let you know that your message really does stick with us. Keep it up!
The following CRM second story is without doubt one of the more harrowing I have ever heard. It was told to me by my good friend Bill Hopkins who was a pilot for Flight for Life in Denver in 1983. Bill eventually went on to have a rewarding career flying as a captain for Continental Airlines.
His recollection of events still gives me chills. What makes the story so compelling is how close he and the flight nurse flying with him that night had come to nearly losing their lives. Here’s Bill’s story:
“Had the flight nurse, Mavis, not been with me to lend a hand to help me control the Alouette III when I had a cyclic hard-over, we would have, without question, died that night,” he told me. “It was February 1983 on a pitch-black, moonless night. We were flying at 13,000 feet over the Colorado Mountains en route to a campground to pick up a patient when suddenly the cyclic had a full right hard-over. With 800 psi of hydraulic pressure fighting against me I was trying with all my strength to try and center the cyclic as we rolled into a steeper and steeper right bank. I wanted to turn off the hydraulics which would have made the emergency more manageable, but I couldn’t release the controls to reach down and twist off the hydraulic knob to do so. I hollered over the intercom to Mavis, ‘Grab the cyclic and help me pull to the left.’ She grabbed the collective instead. I exclaimed, ‘No, no, no, the cylic!’ I told her to put her feet up on the edge of the center console and push with her legs and pull with me on the cyclic, which she did. Now nearing a 90-degree bank on the attitude indicator and descending we managed to bring the helicopter to a wings-level attitude giving me time to reach down to my left and turn off the hydraulic knob. That gave me some semblance of control.
“It was a good thing we’d been flying so high to clear the mountains as we must have lost about 3,000 feet or more before regaining control. I did a slow climb out of what seemed like a black hole until I could see the town of Fairplay in the distance, where we landed. I called our company to tell them what had happened and my company manager didn’t believe me saying, ‘Alouettes don’t have cyclic hard-overs,’
“When our mechanic drove out to where we’d landed, he took the panel off the underbelly of the helicopter. Two retaining pins for the pilot valves that help the pilot move the hydraulic controls on the cyclic, improperly seated, spilled out onto the tarmac. Contrary to management’s assessment of my emergency, I had indeed experienced a cyclic hard-over caused by the improperly installed retaining pins by our helicopter mechanic.
“In a company and hospital meeting to examine the event, it was discovered that the mechanic had worked for six straight weeks (42 days) without a day off or relief. In that meeting I was told by company management to keep quiet about the incident; the implication was that I’d lose my job if I didn’t. I told them that unless another mechanic was hired to share the workload, I would go to the news media and tell my story. Another mechanic was immediately employed by the company. When the meeting ended, the boss of the company took me aside congratulating me on a job well done saying he was going to give me a raise.”
There are several CRM Lessons in Bill’s story: (1) The company culture of working a mechanic to the point of exhaustion, which caused him to overlook installing the pins properly setting up the emergency. (2) Bill’s resourcefulness to ask the flight nurse to lend a hand to help him fight against 800 PSI of hydraulic pressure on the cyclic which was trying to invert the helicopter. (3) Bill’s piloting skills and knowledge of the aircraft systems also proved to help save the day.
Bill and I are Vietnam veterans. He said that looking back on his decades-long career, this incident was the closest he came to losing his life. A strong statement indeed.
Randy Mains is an author, public speaker, and a CRM/AMRM consultant who works in the helicopter industry after a long career of aviation adventure. He currently serves as chief CRM/AMRM instructor for Oregon Aero. He may be contacted at [email protected].