Posted 5 years 243 days ago ago by Randy Mains
A 15 September 2016 article in The New York Times titled “‘Miracle on the Hudson’ Safety Advice Not Carried Out,” had these sobering words:
In the seven years since an airline pilot saved 155 lives by ditching his crippled airliner in the Hudson River, there's been enough time to write a book and make a movie, but apparently not enough to carry out most of the safety recommendations stemming from the accident. Of the 35 recommendations made by the National Transportation Safety Board in response to the incident involving US Airways Flight 1549, only six have been heeded.”
The airline pilot referred to is, of course, Captain Chesley “Sully” Sullenberger, who recently sounded a similar refrain on his Facebook page:
“I’m very disappointed so many of the important safety recommendations made by the National Transportation Safety Board after Flight 1549 have not yet been mandated by the FAA. Unless the FAA mandates safety improvements, airlines historically will not adopt them. We owe it to everyone who flies to act on what is learned from accidents, often at great cost in lives lost, instead of just filing it away to gather dust while we await the next accident.”
You can hear the frustration in his post lamenting the treatment the FAA has given the NTSB safety recommendations. Whereas Sully managed to save the lives of 155 people, our industry has documented well over 1,000 people involved in HEMS accidents, with nearly 400 HEMS crew members losing their lives. That staggering total would fill over six aircraft similar to the one Sully landed in the Hudson.
Sully, welcome to our HEMS world.
The NTSB has carefully studied the problems in our HEMS industry and recommended to the FAA some excellent safety fixes, but similar to Sully’s case, the FAA has refused to act. The reason? According to a 27 August 2012 post at the “Aviation Law Monitor” website, the answer is: “When the FAA was created; it was charged with both regulating aviation and promoting it. The FAA’s inherent conflict of interest explains why the FAA so often ignores FAA regulations.”
That’s why Sully’s statement doesn’t surprise me. He’s now experienced the same inaction by the FAA that we in the HEMS industry have been subject to for years.
After 2008 became the worst year on record in the HEMS industry, the NTSB formed a Board of Inquiry that conducted a public hearing over four days in February 2009. Over 1,000 pages of sworn testimony from over 40 industry experts were generated to determine what should be done to stop the bloodshed. The NTSB then proposed their safety recommendations to the FAA. Several glaring omissions of those life-saving recommendations were evident when the new FAA rules were announced five years—and 23 more deaths—later.
If you read the earlier safety recommendation document written in 2009 by the then head of the FAA, Randy Babbitt, (and signed off on by the then head of the NTSB, Deborah Hersman, in September of that year) Babbitt wrote the following under the heading “Dual Pilot/Autopilot Use”:
"A review of the NTSB Aviation Accident Database revealed that during the 8-year period from 2000–2008, 123 HEMS accidents occurred, killing 104 people and seriously injuring 42 more. All but nine of these accidents involved operations with only one pilot. Pilot actions or omissions, in some capacity, were attributed as the probable cause in 60 of the 123 accidents. Most of these 60 accidents might have been prevented had a second pilot and/or an autopilot been present."
The FAA chose to ignore the NTSB recommendations because it would have put too great a financial burden on the smaller operators, giving further ammunition to the argument that our system in America needs a change if we ever expect to see a reduction in HEMS accidents.
Robert Sumwalt, chairman of that 2009 Board of Inquiry, voiced his personal frustration with the FAA in a January 2016 post on the “NTSB Safety Compass” blog:
“As evidenced by continued HEMS crashes, more needs to be done. NTSB crash investigations have demonstrated the safety benefits of scenario-based simulator or simulator training, use of NVIS, and a second pilot or an autopilot. After all, an industry that is designed to save lives should not be claiming lives.”
In the FAA’s defense, the agency is seriously shackled by its own mandate. Two friends of mine quit the FAA in Washington, voicing their frustration at politics that hampered creating meaningful rules to save lives. Good, well-meaning, hardworking people working in the FAA know the problems we in HEMS face. They have told me they would like to do more, but lack the power to do so because of the nature of the lumbering beast they work under.
Here’s a good example of how the agency hesitates to act. The FAA manager of general aviation attending the EAA AirVenture Oshkosh air show in Wisconsin this past August was interviewed on camera by a reporter from station KUSI. When asked when he thought the FAA was going to do something to “fix” fuel systems that aren’t crashworthy (reportedly in over 5,000 helicopters currently flying) the general manager replied, “I was at a point where I would not fly in a helicopter that didn’t have the (fuel system) upgrades. Industry can stop producing aircraft that don’t have crashworthy fuel tanks. Helicopter manufacturers need to shoulder much, if not all, of the responsibility. We (the FAA) try not to hamper growth.”
By inference, the FAA won’t act to fix a known problem, even one as deadly as faulty fuel systems that have incinerated survivors in otherwise survivable crashes, because to fix the problem would hamper growth in the industry. By their inaction, the FAA is in effect putting a value on human life.
Sully’s recent experience with FAA inaction, in parallel with our experiences in HEMS over the years, is an indication that our system is in need of serious revamping. Anyone on the street will tell you that air safety must be paramount, no matter how it affects the bottom line. As Sully points out, your life and my life depend on it.
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]