Close Calls and Lessons Learned

One of the very first things I figured out when I first started flying many years ago, was that no matter how insignificant the lesson, I learned something new on each and every flight. Sometimes it is something brand new to me, other times it is a reminder of a lesson I'd forgotten about (I try my best to remember, but I'm nowhere near perfect). Sometimes the lesson is the obvious and in-your-face kind, other times it is more subtle and I have to look for it, but it's there nonetheless. Point being, I always have something to ponder while I walk back to my car.

Two days ago, I was confronted with one of the major, obvious, literally-in-my-face kinds of lessons. And quite honestly, I don't care if I never learn another lesson that way again.

I'll start in the time honored hangar flying tradition...slightly edited for content:

No Kidding, there we were... the last landing of my annual Army C-12 checkride. I had just completed a raw data, single engine, hand flown ILS with a circle to land clearance. Feeling fairly proud of the job I'd done so far, I had just turned about a 1/2 mile final to RWY 36 and was intent on greasing the landing. I was on speed and on about a 3* glide path, best I could tell. We'd been cleared to land coming accross the LOM on the ILS, the gear was down and flaps had just gone from Approach to Full (Only done on a single engine landing when the pilot is sure he can make it to the runway). We came over the fence at about 100'agl and about 105kias. VRef was about 95, so I was right where I wanted to be. All was good. Right up until I saw the flash.

Rwy 36 is a concrete runway, and about 1/2 to 2/3 of the way down the runway is a dark spot from where water pools after it rains. It's been there for years, and if you're looking at it just right from far away, it can look like there is an aircraft on the runway. As I focused on the far end of the runway for the flare and touchdown, I noticed that today, for some reason the dark spot had a red anti-collision strobe light. Flash! That's not a dark spot. That is the shadow of a Bell 206 on the centerline of the runway, about 2000' in front of me!

100' agl and Vref +10kts with full flaps and gear down is NOT where you want to be when you decide to make a single engine go-around. There is even a caution in the POH about attempting a single engine go-around with full flaps. It says it "May not be possible". Meaning, if you try it, you're on your own and Beechcraft is not responsible for any purchase of agricultural property.

Well, I had two options at this point. Go around and hope I make it, or put the airplane on the runway and try to avoid the helicopter on the runway, as well as the gaggle of 206's to either side of the runway in the grass (probably 15 of them within 100 feet of the runway on either side). The second engine was still running, albeit with the throttle at idle and the prop feathered, we were light on fuel, and had no cargo or passengers, it was a cool day and the DA was low. We were going around. In the split second it took me to make this descision, I alerted my IP to the aircraft on the runway in front of us. He in turn, asked the tower if there was in fact another aircraft on the runway. After a brief pause, the controller came back with "Army 12345, GO AROUND! GO AROUND!"

What happened next seemed at the time to happen in slow motion, but looking back, it is a blur. All at once I reached down and grabbed both throttles and shoved them to the firewalls, summoning all 1700 horses that Mr. Pratt and Mr. Whitney had built into those two fine powerplants bolted to the wings on either side of me (850 per side). We (the IP and I) are still unsure about who moved the left prop from the feather position up to full RPM, but it was done and thats all that mattered at that point. The IP brought the flaps from full down up to the approach position while the prop slowly came out of feather. We were hanging about 85' in the air at just over 100 knots as we limped past the 206 (We flew over the sod between the runway and the parallel taxiway), still waiting on the runway, evidently unaware that he was in any danger. I made the descision to leave the gear down in the event the airplane did not climb. Fortunately for all involved, it did finally start to climb as the #1 engine came back to life. Ok. Gear up and flaps up. Enter left traffic for 36.

The controller instructed the 206 to move off the runway to an adjacent pad. He then told all other aircraft to hold position as he (I'm sure) took a deep breath and breathed a sigh of relief. He wasn't alone.

We came around, and once again were cleared to land on Rwy 36. This time with both engines running, and all eyes on us. I did get my greased landing, rolled out next to the 206 in question, turned off and taxied to parking. Shut down was uneventful, and I got out to chock the airplane. When I reached down to grab the chocks, I noticed my hand shaking...the adrenaline was wearing off.

After securing the airplane, we walked over to the tower and talked with the extremely apologetic tower manager. The explaination was that it was a mistake. Plain and simple.

The chain of errors was pretty easy to follow from that point on, and it was not just the controller who was at fault.

Strike 1: The controller had given the 206 a position and hold clearance pending an IFR release about 10 minutes prior to our incident and had subsequently forgotten about him on the runway.

Strike 2: Come to find out, the pilot (Instructor) in the 206 heard the controller clear our King Air (And a following T-34C) to land on Rwy 36. He even went so far as to acknowledge to his student that "That's not good", but then failed to take any sort of corrective action to deconflict the situation. His blind faith in ATC could have cost him and his student their lives.

Strike 3: My own complacency regarding the "Dark spot" on the runway. I think in hindsight, I actually saw the shadow of the aircraft (The aircraft itself was all but invisible. It was a slender white aircraft, aligned with the centerline of a concrete runway) but passed it off as the known "dark spot" at about the same point on the runway. I did not see the AC light until I was just over the runway, and under slightly different conditions, that might have been too late. I should have continued to check the "dark spot" until I could clearly identify it one way or another. Lesson learned.

In this case we had three strikes against us, but made it out alive and unharmed. We got lucky but also had several things working in our favor. We were unusually light for a King Air, we had a very low DA, and had two experienced pilots (One Pilot in Command and one Instructor Pilot) at the controls working together as a crew should. I'm not trying to brag at all, just pointing out that if it had been a different crew mix, say with a low time Co Pilot, the results might have been different.

As a result of this incident, I was told that the tower would consider revising it's SOP regarding position and hold clearances, and would retrain it's controllers immediately.

I personally have no ill feelings whatsoever towards either the controller or the pilot of the Bell 206. They are both highly experienced professionals, and we all got caught making simple, honest, human errors. These things happen. It's what we do about it afterwards that counts.

Fortunately for all involved, we all walked away and nothing was damaged with the possible exception of two overtorqued King Air engines (still pending maintenance checks). I think valuable lessons were learned by all involved, and I hope we can use this example to teach others and hopefully prevent injuries or fatalities in the future.

If you have similar lessons learned, please feel free to share them. I wanted to share this incident with the board both as a learning tool for future reference, and as a way for me to vent, document and move on. It was a scary experience, and one that could have easily ended tragically, but it didn't, so now it's time to learn and get back to bidniss...

Another one

Adrenaline is a funny thing. It has a kind of "slow motion" effect on me. Things that actually happen in seconds or minutes seem to take exponentially longer, yet when you look back on them after the adrenaline wears off, the event seems like a blur.

For whatever reason, April must be my month to learn the "In your face" kind of lessons I mentioned in my first post. It happened again yesterday. This time however, it was not just a series of honest mistakes. It was someone intent on killing himself, and if needbe, my crew and I as well.

In my civilian job, I fly an EMS AStar in a quiet little central Arizona town. Quiet except for the 4 or 5 large prison complexes in town. While we do a fair amount of auto accidents, chest pains, ATV accidents, etc, about half of our call volume is generated by the prisons. Flying sick prisoners is nothing new to me, but my whole outlook on prisoners changed permanently yesterday.

It was early afternoon, on what had been an unusually quiet Monday. We received a dispatch for one of the larger prisons, and 4 minutes later, we were in the air. 2 minutes after takeoff, we were on the prison pad waiting for the patient. At first we were unsure as to whether or not we were flying an inmate, or just using the helipad to rendezvous with the ambulance. When we saw the ambulance emerge from the fortress that was the prison, we kinda put two and two together.

Prison calls are a bit unusual in that there are only two hospitals that are able to accept prisoners, and a Corrections Officer always rides along as an escort. The latter fact was always sort of a comfort, until yesterday.

As my crew brought the patient to the aircraft, I could see that he was a small (maybe 5'3", 120lbs) yound man. He had apparently overdosed on something, with the intent of comitting suicide. (How Prisoners ever get access to enough of anything to overdose is beyond me...). With suicide/psychiatric patients, there is always an added level of caution when deciding whether or not I want them laying 14 inches from me and my flight controls. This guy appeared to be all but unconscious, and was in the normal travel shackels (hand cuffs and ankle cuffs with a chain running between the two sets) as well as belted to the backboard in 6 different places. The belts were tight and I was comfortable that the patient would be secure for the 18 minute flight.

We took off and headed towards Phoenix (An anomaly that turned out to potentially be a life saver. I will explain later.). For the first 10 minutes, the patient remained catatonic, barely able to open his eyes no less move his arms or legs. That changed in a matter of seconds. Out of the corner of my eye I caught some rapid movement, and turned to see the patient biting the monitor cords and his IV line. My med crew began trying to wrestle the cords away from him, but then he turned on them and tried to bite them as well. The patient had gotten his arms free from the seatbelt straps at this point (The travel shackels do not prevent movement, they just restrict movement so the inmate cannot raise his arms above about chest level in a normal size patient. But this guy was small...) and began flailing his arms about, at one point grabbing the IV needle and threatening the crew with it. Somehow, they were able to get it out of his hands, but then he was able to reach down and undo the seatbelts securing his legs. That's when all hell broke loose. He started kicking at the windshield and instrument panel, and at this point only had shoulder straps and one seatbelt across his chest keeping him on the backboard. The med crew was doing an incredible job of restraining this guy, but given the layout of the AStar, they could only attempt to control his upper body, and as much as he was thrashing about, it wouldn't have taken long for him to get completely out of his straps. This guy wanted to die, and didn't care who he took with him. It wasn't going to be me or my crew. Thats all I cared about.

As soon as I saw his legs come loose, I began to look for a place to land. It is amazing how many landing options become available when you have an emergency. I saw an empty 7-11 parking lot, a cul-de-sac, a small dirt lot between two homes, but then I saw the baseball field. Nobody on the field, it was a large landmark that Police and EMS would be able to find quickly, and there were people in the general area who might be able to help. That's where we were going.

I looked for a wind indication, saw a big flag and set up to land on the baseball field. On the way down, I called my dispatch to let them know that we were making an emergency landing and to please alert the local Police Dept that we had an inmate who had come out of his restraints and was fighting with my crew. 30 seconds later we were on the ground in center field with the blades coasting down and my medical crew still wrestling with this guy like I've never seen. I don't think they even realized we were on the ground for a minute or two after.

As soon as the blades stopped, I ran over to assist the crew. I secured his legs and ratcheted the straps down with all my 245lbs. This guy wasn't going anywhere anytime soon.

I asked one of the baseball coaches to call 911 and ask for police and an ambulance. I had no idea what the name of the school or the address was, so I figured it was easier to have one of the school officials take care of that. They were happy to help and I thank them for all of their assistance.

About two minutes after landing, a police officer on a bicycle arrived. He worked at the school and had called in a priority response on his own radio. 3 minutes later there were probably 15 police cars and 25 officers standing over this guy, as well as the Police helicopter (Thanks again Falcon 3!) orbiting overhead. It was really comforting to see such a huge response.

The ambulance arrived shortly thereafter, and the patient was sedated and loaded for transport. My medical crew went with them, along with a police escort just in case this guy got out of hand again.

After the ambulance left, I went around and thanked all the police officers and school officials. I passed out some stickers and pens, and gave them all our contact info in case they had any questions about anything.

I strapped back into the AStar, and took a few deep breaths. the solo flight to the hospital to pick up my crew was therapeutic and I enjoyed it immensely.

After we got back to base and sat down to discuss the events of the day, I realized there were some important lessons to be learned.

First of all, my new SOP is that ANYONE coming out of the prison WILL BE secured to the backboard at their wrists and ankles so that they are completely unable to move their arms or legs. I don't care if it's a jaywalker or an axe murderer. No inmate will be in my helicopter without being completely and securely immobilized.

Secondly, I will no longer wait for the patient to get so out of control as to present a clear threat to the safety of my crew and I before looking for a place to land. Looking back, I realize that my delay in landing could have been a deadly mistake. From now on, any sort of combativeness from an inmate (or any patient for that matter) will constitute at least a precautionary landing if my crew is not able to immediately chemically restrain the patient. An AStar is no place to be fighting with a patient.

Thirdly, I will no longer take any comfort in, or expect any assistance from the Corrections Officer. The CO in this instance turned out to be nothing more than another onlooker. She was so traumatized once we landed that she froze and provided no appreciable amount of assistance with the inmate she was supposed to be guarding. I am not blaming her personally, as it was a traumatic experience for all of us and we all handle stress differently, but she was of no help at all in this situation. In her defense, from her seat in the aircraft, there was no possible way for her to assist while in flight and I think the gravity of the situation hit her pretty hard after we landed and she just froze. It happens.

Lastly, it was only after I took off from the baseball field that I realized I was still within the lateral boundaries of the Class D airspace of the local airport, and that I hadn't explained to the tower what was happening. The last they knew, I was heading to a hospital in Phoenix. I can only imagine what they were thinking when they saw my blip disappear from radar. I apologized and explained that I didn't have time to get an ATC call off, and once on the ground I'd completely forgotten about them. They understood and said they were just glad we were safe. I re-learned that second only to flying the aircraft, communication is a must.

Earlier I mentioned that it was an anomaly that we were sent from this prison to a Phoenix hospital. Normally this prison uses a hospital in Tucson for medical patients (Trauma patients always go to the closest facility, which is Phoenix). It struck me as odd when my nurse told me we were going to Phoenix, but I didn't question it because the hospital in PHX was 10 minutes closer. It occured to me after the flight that if we'd been enroute to Tucson, we'd have landed out in the middle of the barren desert, and it would have taken law enforcement upwards of 45 minutes to get to us. All while we fought with a suicidal/homicidal inmate. Instead, we had an enormous and almost instant police response. Thank God for little favors. Our guardian angels were looking out for us yesterday.

I would like to pass a special word of thanks to my medical crew. They're the heroes in this story. They wrestled with this patient (while he was trying to bite and stab them) and kept him as secure as they could. There is no doubt in my mind that if this patient had been able to get completely loose, he would have either opened the door and jumped, or attacked me with the intent of crashing the helicopter.

I hope nobody else has to learn this particular kind of lesson the way I did. It was one of the scarier experiences I've had, and hindsight only makes it clearer the kind of danger we were actually in. If any of you are ever in the position to make a similar flight, please, take my lessons learned to heart. It may save your life.

Pilot in Command Lesson

Yesterday, my crew and I were called to a scene in a residential neighborhood. The fire department had set up a nice big LZ on the street in the neighborhood. All looked good from the air.

Upon landing, we found the street was just packed gravel and was fairly dusty. No big deal in and of itself, but the ambulance was behind the aircraft, and due to wind conditions (about 20 kts out of the Northwest) I did not want to turn the nose to face the ambulance (coming from the South). I decided to shut the aircraft down on the scene to avoid anyone approaching the running aircraft from the rear, even tho I knew my crew would ensure that nobody approached the tail rotor. I also did not want to dust the ambulance and the patient when they opened the doors. Right after we landed, I noticed all of the looky-loos coming out of the woodwork (and their houses) to watch the goings-on, and this only confirmed my decision.

I sent the medical crew back to guard my tail rotor until the blades stopped, and then got out of the aircraft. I chatted with the LZ commander for a few minutes, and explained my reasons for shutting down. He didn't seem to mind and in fact agreed that it was the safest option.

On the way to the hospital, my flight nurse told me that the FD Captain (who was in charge of the entire scene) was "very upset" that I'd shut the aircraft down. For whatever reason he wanted me to leave it running and apparently, he put my crew thru his version of the Spanish Inquisition trying to find out why I shut down. The crew explained that it was for safety reasons, but he wasn't satisfied. He said "you should have picked a different LZ if you didn't like this one!". He never did talk directly to me about it.

The fact is, there was nothing wrong with the LZ itself, just the variables surrounding it. There were issues I was not comfortable with, so I solved the problem by shutting down. I made sure that doing so would not adversely affect the patient, and was assured that it would not.

The lesson here is that as the Pilot In Command, you are the sole authority for the operation of your aircraft, no matter what someone else says. The fact that Fire Captain Schmuckatelli didn't agree with my decision and was "very upset" doesn't concern me in the least. My job is to keep my crew and passengers safe, as well as ensure that anyone on the ground near my aircraft is safe. My job is not to appease someone who did not have all the pertinent facts. If it was that important to him, he could have discussed it with me face to face.

Learning how to stand up for yourself and defend your decisions is not something you're taught in training, but is one of the toughest and most important lessons to learn as a professional pilot. You are the Pilot In Command, and you are the only one who will have to answer for your actions if something goes wrong or someone gets hurt. Just because some crunchy (Army term for a person on the ground... that's the sound they make when you land on them...CRUNCH!) says you should have done it his way doesn't make it so. It's all about doing what YOU think is right, all the time, every time.

There was a time when I would have let that incident adversely affect my future decision making, and that is a dangerous condition. Fortunately for me, I learned my lesson by watching what happened when someone else let somebody talk him into doing something he knew wasn't safe. I hope I can help someone else learn the same lesson without somebody getting hurt.

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