Jan 24 2022

CRM WORKS Reach Air Medical Services Posted 2 years 337 days ago ago by Admin

I often wish a bell would ring when an accident or incident is prevented when crew resource management, CRM, is practiced.  On occasion, however, a bell does ring for me when people send me a personal CRM story or recall an incident they heard about.  They usually let me know via email or Linkedin or in this recent case my friend, Joe Mattern, sent me a direct message on Facebook informing me of an event where CRM most likely saved the lives of all on board their air medical helicopter that night.

Joe Mattern has been following me on Facebook for many years and he knows how committed I am to teaching and facilitating CRM courses which is my personal way to try to bring down the accident and incident rate in helicopter aviation.  Joe came across the following report on the Concern Network where incidents and accidents are reported as a way to educate others in the industry so that they can learn from them.  The following is a report that details how an alert air medical crew member, unafraid to speak up, saved the day.

Reach Air Medical Services - Non-Injury Incident

DATE June 28, 2021

TIME  17:37

TIME ZONE  PST

PROGRAM   Reach Air Medical Services

WEATHER    28011KT 10SM FEW002 BKN006 16/13 A2986

AIRCRAFT TYPE    EC-135

TEAM MEMBERS   Pilot, nurse, medic

BACKGROUND:

The following is a description of a EC-135 Helicopter Instrument Flight Rules operation (IFR) event. While returning from San Francisco International Airport on a filed IFR plan to the home base of Merced, California, the aircraft attitude, and normal flight parameters were not maintained in IMC conditions. The condition was quickly recognized by the flight team. The flight team announced the condition alerting the pilot and aiding him in making the most effective return to normal flight (CRM).

Initial Actions:

1) An initial Safety-Alert Notification was distributed for all crew members to convey the importance of CRM and to celebrate the skillful application of those skills in this circumstance.

2) A Root Cause Investigation has been conducted and all findings are reported below.

3) The Director of Operations reported the incident to all appropriate government agencies.

ADDITIONAL INFORMATION:

It is our desire to share our findings and recommendations in support of the safety of all involved in air medical transport.

CAUSAL FACTORS:

The pilot had a breakdown in IFR scan during the departure phase of the flight.

FINDINGS:

1) CRM was found to be key in the successful return to normal flight.

2) The crewmembers speaking up and noticing the decay in airspeed had a distinct and positive effect on the safe outcome (CRM).

FOLLOW UP ACTIONS:

1) The FAA has been notified of this event and the investigation has concluded and been closed by the Organization Root Cause Analysis Board.

2) The training department has implemented a training focus to enhance awareness of the critical nature of IFR fundamental skills as well as specific operational step and system mode verification procedures.

3) Departure procedures continue to be fully briefed and understood by the entire crew. To foster CRM, the Instrument procedure must be displayed on the EFB (Airport diagram for taxi, IAP for arrival, etc.)

4) CRM is a tremendously powerful tool. The skillful use of CRM in this case significantly contributed to the successful return of the aircraft to a normal flight condition and safe landing.

From day-one of its inception in 1981, one of the key tenants of CRM theory is advocacy—a crewmember’s belief, through their CRM training, that they not only the right but the responsibility to themselves and their fellow crewmembers to speak up if they have a question, a concern, an observation or pertinent information they might have to ensure the safety of the flight.  Additionally, they have the expectation to be taken seriously and listened to without fear of reprisal or personal criticism. 

What is very evident and indeed heart-warming to me in this incident, is that Reach Air Medical Services appears to be an organization where a team member’s input is encouraged and valued and in this case most likely prevented a fatal accident.  As Sully Sullenberger advocates, “It’s about what is right not who is right.”  He goes on to say, “Even the most junior flight attendant could approach the most senior captain with a concern and be heard.”

Interestingly, before famously landing his plane on the Hudson River that day saving the lives of all 155 people aboard, Sully had been a CRM instructor for over 14 years.

My first exposure to CRM was in 1982 and I know its value, indeed its power if practiced diligently, in ensuring everyone makes it home safely.  It is my great wish the practice demonstrated by the Reach crewmember that night in speaking  when they had a concern, will one day be the norm in helicopter air ambulance, HAA, and not the exception.   

About Randy:
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].