Emergency Medical Service Incidents - ASRS · PDF fileEmergency Medical Service Incidents . ... learned that the airport was closed for runway resurfacing. ... go-around due to a coyote

ASRS Database Report Set

Emergency Medical Service Incidents

Report Set Description .........................................A sampling of reports concerning Emergency Medical Service (EMS) incidents.

Update Number ....................................................18.0

Date of Update .....................................................May 31, 2017

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............12

Type of Records in Report Set .............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

Report Synopses

ACN: 1425113 (1 of 50)

Synopsis ZBW Controllers reported that an aircraft was descended below the Minimum IFR Altitude

in error to get it below clouds to see the airport.

ACN: 1425045 (2 of 50)

Synopsis Air ambulance helicopter pilot reported a failure to complete the flight risk assessment

process due to iPad communication problems in a rural area.

ACN: 1421777 (3 of 50)

Synopsis ZLA Controller and Helicopter pilot reported of incorrect information which led to an

Airspace Deviation. The Controller had advised the pilot that the restricted airspace was

inactive, approved the flight through the airspace when the airspace was actually active

ACN: 1421137 (4 of 50)

Synopsis Helicopter pilot reported encountering icing conditions and landed at the nearest airport.

ACN: 1408366 (5 of 50)

Synopsis A TRACON Controller reported a departing aircraft in conflict with an overflight helicopter

they were working.

ACN: 1405035 (6 of 50)

Synopsis EC-130 pilot reported attempting to set down on a dolly with a tailwind, but hit a skid on

the dolly and pulled the collective to ascend. Sensing what the pilot thought could be

dynamic rollover developing, he landed the helicopter. It was determined that a skid had

caught on the dolly.

ACN: 1399837 (7 of 50)

Synopsis Helicopter Captain reported encountering IMC conditions during a night VFR ambulance

flight. Pilot reported a turn to return to VMC and mentioned that wearing Night Vision

Goggles can make it difficult to detect reduced visibility conditions.

ACN: 1398441 (8 of 50)

Synopsis A Maintenance Technician reported that During Track and balance on a EC-135 Helicopter,

a Main Rotor blade was needed. Upgraded the existing blade per a Service Bulletin.

ACN: 1396857 (9 of 50)

Synopsis A Pilot of a Piper PA28R reported while setting up for a flight maneuver they nearly

collided with a medical helicopter.

ACN: 1396205 (10 of 50)

Synopsis Air taxi Captain reported experiencing a NMAC with a C172 on approach to the non-

Towered AAO airport.

ACN: 1392986 (11 of 50)

Synopsis ZLC Controller reported observing an aircraft at 10,000 feet in a MVA area designated

11,000 feet.

ACN: 1390677 (12 of 50)

Synopsis Air carrier flight crew described the confusion resulting from the First Officer mistakenly

confirming aircraft established on a VOR radial, instead stating the aircraft heading which

confused ATC.

ACN: 1381828 (13 of 50)

Synopsis A helicopter pilot reported difficulty maintaining the FAR required altitude above terrain

due to a lowering weather ceiling and rising terrain.

ACN: 1375426 (14 of 50)

Synopsis C90 Captain reported being awakened from sleep to fly a medevac flight but not

comprehending the assignment due to fatigue. When informed that the flight is ready to

depart he quickly jumped in the aircraft without checking NOTAMs. After landing he

learned that the airport was closed for runway resurfacing.

ACN: 1372997 (15 of 50)

Synopsis

Air ambulance flight crew landing at RLD reported a near collision with another aircraft

taking off on an intersecting runway. The other aircraft reportedly was not communicating

on CTAF frequency.

ACN: 1368320 (16 of 50)

Synopsis An Air Traffic Controller Trainee reported failing to take sufficient action to keep a VFR

aircraft away from an IFR aircraft executing an approach to an airport. The Trainee

Controller mistakenly believed he could not vector the VFR aircraft below the MVA.

ACN: 1364396 (17 of 50)

Synopsis CHS Tower Controller reported of a problem with traffic into the airport. The pattern traffic

was working until the reporter was given a point out on a Lifeguard aircraft which caused

the pattern to be disrupted and caused a wake turbulence problem.

ACN: 1361710 (18 of 50)

Synopsis Medevac helicopter pilot reported being advised of a UAV which was operating in the

vicinity of his proposed flight path. This information caused him to be distracted which

resulted in his non-compliance with company risk assessment procedures.

ACN: 1359784 (19 of 50)

Synopsis An EMS helicopter pilot reported hearing an iPad notification sound which he thought

indicated Dispatch's mission approval after his risk assessment. In fact, Dispatch wanted

to discuss weather. A distinctive Dispatch approval notification "ding" was discussed as a

solution.

ACN: 1356741 (20 of 50)

Synopsis An EC-135 EMS pilot landed for patient pickup, but because the patient had expired, the

flight returned to base. The pilot started his takeoff with an engine in idle, but landed

immediately, returned the engine to fly and departed. Upon arrival he discovered a CAD

FADEC #1 "ENGINE EXCEED" alert so the aircraft was removed from service.

ACN: 1354660 (21 of 50)

Synopsis Several ATC Controllers reported that an aircraft was allowed to get less than the required

distance from an active ATC Assigned Airspace. A Controller had used incorrect procedures

to allow the aircraft to proceed toward the airspace.

ACN: 1351591 (22 of 50)

Synopsis ZLA Controller and two flight crews describe a serious airborne conflict which developed

after an air taxi inexplicably climbed from their assigned FL270 into an air carrier at FL280.

The aircraft at their closest were 100 feet vertically and about 1 mile horizontally.

ACN: 1350521 (23 of 50)

Synopsis EC135 medevac pilot reported encountering unannounced jumpers in the air on arrival to

an uncontrolled airport.

ACN: 1350154 (24 of 50)

Synopsis During scheduled maintenance on a Helicopter ECD-EC135 a mechanic safety wired an O2

bottle manual shutoff valve in the closed position when it should have been in the open

position.

ACN: 1348316 (25 of 50)

Synopsis The Captain of a medevac helicopter flight reported that an external inspection access

door opened in flight and struck the rotor blades. The flight landed safely and there were

no injuries reported.

ACN: 1345784 (26 of 50)

Synopsis MBB BK-117 pilot reported they had a GEN OVHT caution light which required a shutdown

of the number one engine. Successful landing was made at an airport.

ACN: 1343602 (27 of 50)

Synopsis AW-139 helicopter pilot reported an NMAC when they took off without clearance.

ACN: 1343584 (28 of 50)

Synopsis BH206 pilot reported an NMAC on final to a hospital helicopter pad.

ACN: 1341241 (29 of 50)

Synopsis

C182 pilot reported being admonished by the SMO Tower Controller for crossing CULVE

below 1120 feet during the VOR Approach to SMO in VMC. The VOR Approach is a circle to

land only approach with an MDA of 680 feet.

ACN: 1339538 (30 of 50)

Synopsis Helicopter pilot reported a loss of GPS signal on both Garmin units during departure from a

hospital. The outage lasted 10 seconds on the G530 and three to four minutes on the

G430.

ACN: 1330540 (31 of 50)

Synopsis CE560 flight crew experienced a strong rolling tendency and aileron trim binding during

initial climb then the controls are passed to the PIC in the right seat. The crew elects to

return to the departure airport and the PIC is able to adjust the aileron trim to neutralize

the rolling tendency prior to landing.

ACN: 1329046 (32 of 50)

Synopsis HWD Tower Controller reported of Class Delta airspace violation. The Controller working

the Approach Control position was called by HWD Tower Controller and asked about the

violating aircraft. Converging traffic was being worked by the Tower Controller. Overlying

TRACON Controller never asked for a point out or advised that visual separation was being

used.

ACN: 1327145 (33 of 50)

Synopsis FXE Tower Controller reported a recurring problem with coyotes. An aircraft was issued a

go-around due to a coyote on the runway. A landing aircraft reported almost hitting a

coyote on the runway.

ACN: 1322533 (34 of 50)

Synopsis An AS-350 pilot described a helicopter dolly rotating on an icy ramp during engine start

while preparing to fly off the dolly.

ACN: 1320955 (35 of 50)

Synopsis An aircraft was climbed through a Controller's sector without a handoff or point out.

ACN: 1318864 (36 of 50)

Synopsis CRP TRACON Controller reported an opposite direction landing and takeoff occurred at CRP

airport with less than the required miles of separation according to the local directives.

ACN: 1318643 (37 of 50)

Synopsis An aircraft departed with a known radio/navigation component malfunctioning. In flight

the pilot noticed the aircraft's transponder, clock, and standby attitude indicator had failed.

ACN: 1317220 (38 of 50)

Synopsis PHL Local Controller reported a loss of separation when a helicopter passed under an

aircraft transporting skydivers. The Controller had not been advised that the jumpers had

exited the aircraft. Reporter noted a lack of communication between TRACON and Tower

supervisors.

ACN: 1315961 (39 of 50)

Synopsis Flight crew reported lining up for HUA airport instead of their destination, HSV, during a

night visual approach.

ACN: 1309600 (40 of 50)

Synopsis A helicopter pilot called ATC after a NMAC with an UAS at 1,400 feet over the STL

metropolitan area.

ACN: 1309270 (41 of 50)

Synopsis An air taxi flight crew reported an issue with the ILS Runway 6L signal at CLE that caused

an unexpected pitch up and down with the autopilot engaged.

ACN: 1307864 (42 of 50)

Synopsis ARTCC Controller reported an aircraft calling with an unreadable request, but the

Controlled believed the aircraft was in distress. Aircraft was at 3600 feet descending and

reversing course. Controller improperly issued aircraft a VFR clearance and sends them to

TRACON even though the aircraft was IFR and wishing to remain as such.

ACN: 1307731 (43 of 50)

Synopsis An employee reports he was informed by their Lead Mechanic that a Mandatory Service

Bulletin inspection of Engine Front Support Pins issued by the engine manufacturer for

their BK-117C1 Eurocopters also included a logbook entry requirement after the last flight

of the day. The logbook entry requirement had not been included in the pilot maintenance

checklist/signoff form from their company.

ACN: 1305430 (44 of 50)

Synopsis Local Controller working Ground combined reported that hour breaks are common at this

facility and safety is being jeopardized. Controller was too busy at times and because of

this aircraft were delayed. Controller recommended keeping ground control open during a

specific time.

ACN: 1295901 (45 of 50)

Synopsis An SJU Controller failed to issue a full route clearance after missing the note in the

remarks of the flight plan. Aircraft became airborne on a closed airway.

ACN: 1294768 (46 of 50)

Synopsis Bell 407 pilot reported he had a TFR incursion and stated the TFR was not listed on the

FAA briefing website. Both TFRs were for sporting events.

ACN: 1294332 (47 of 50)

Synopsis Several Maintenance Technicians reported difficult working conditions that resulted in

maintenance errors including the possible installation of the incorrect part number.

ACN: 1292795 (48 of 50)

Synopsis An air taxi crew at 6,000 ft was issued a traffic advisory at 5,500 ft by ROA TRACON on

vectors for ROA. The crew did not see the aircraft but responded to a TCAS RA CLIMB with

the traffic 500 ft beneath.

ACN: 1286321 (49 of 50)

Synopsis AS350B3 helicopter pilot reported two NMACs with crop dusters during flight.

ACN: 1284059 (50 of 50)

Synopsis A helicopter pilot preparing to depart a Charleston area hospital helipad attempted

clearance into CRW Class C, but could not hear ATC and so hovered at 100 feet until

cleared. ATC was upset that he took off, but communications from area hospital helipads is

poor.

Report Narratives

ACN: 1425113 (1 of 50)

Time / Day

Date : 201702

Local Time Of Day : 1201-1800

Place

Locale Reference.ATC Facility : ZBW.ARTCC

State Reference : NH

Altitude.MSL.Single Value : 3100

Environment

Flight Conditions : IMC

Weather Elements / Visibility : Icing

Aircraft

Reference : X

ATC / Advisory.Center : ZBW

Aircraft Operator : Air Taxi

Make Model Name : Light Transport

Operating Under FAR Part : Part 135

Flight Plan : IFR

Mission : Ambulance

Flight Phase : Descent

Route In Use : Vectors

Route In Use : Visual Approach

Airspace.Class E : ZBW

Person : 1

Reference : 1

Location Of Person.Facility : ZBW.ARTCC

Reporter Organization : Government

Function.Air Traffic Control : Enroute

Function.Air Traffic Control : Departure

Function.Air Traffic Control : Approach

Qualification.Air Traffic Control : Fully Certified

ASRS Report Number.Accession Number : 1425113

Human Factors : Distraction

Human Factors : Situational Awareness

Person : 2

Reference : 2



Function.Air Traffic Control : Handoff / Assist





Human Factors : Confusion

Person : 3

Reference : 3



Function.Air Traffic Control : Supervisor / CIC


Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 5


Human Factors : Time Pressure




Events

Anomaly.Airspace Violation : All Types

Anomaly.ATC Issue : All Types

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Inflight Event / Encounter : Weather / Turbulence

Detector.Person : Air Traffic Control

When Detected : In-flight

Result.Air Traffic Control : Provided Assistance

Result.Air Traffic Control : Issued Advisory / Alert

Result.Air Traffic Control : Issued New Clearance

Assessments

Contributing Factors / Situations : Airport

Contributing Factors / Situations : Airspace Structure

Contributing Factors / Situations : Human Factors

Contributing Factors / Situations : Procedure

Contributing Factors / Situations : Weather

Primary Problem : Weather

Narrative: 1

Aircraft X was trying to land at CYES (an uncontrolled airport without an instrument

approach). I descended him to 050 for arrival. I advised him of moderate rime icing in the

vicinity from a PQI departure with the altitudes and temperature. I advised him that no

weather was available for CYES and offered him the FVE weather since it was the closest

airport. I provided him the FVE special observation and advised him to contact FSS for the

current NOTAMS. He advised that his intentions were to land at CYES visually and advised

that his plan was to fly the RNAV approach into FVE via the IAF if he was unable to get the

field in sight. He asked for a lower altitude to get ground contact.

I descended him to 031 which is the Minimum IFR Altitude (MIA) around PQI. Montreal

center called to get an updated departure time for Aircraft X and advised that they were

blocking the airspace for him. By this time the complexity of the sectors was rapidly

increasing due to weather and increased traffic. I provided Aircraft X with the updated

weather at FVE and asked his intentions. He wanted to continue and try to get the field in

sight. The PQI departure that had reported moderate rime icing was now reporting severe

icing and requesting a climb to avoid.

I called the Controller in Charge (CIC) over to report the severe icing while getting further

reports from [the PQI departure]. A D side was provided at this time and while they were

being briefed, I noticed that Aircraft X had entered the 035 MIA. I told Aircraft X that if he

didn't have the field in sight that he needed to climb to 035. He advised that he did not

have the field and was climbing. He stated that he couldn't get the field in sight and

wanted to fly the RNAV for FVE. He was issued a right turn to 110 to avoid a higher MVA.

While this was occurring, a BGR departure (which I leveled at 100 due to a BGR arrival at

110) reported moderate rime icing at 100. This report was passed to an ALTRAV that was

entering the sector that was also landing BGR. I asked the CIC to split the sectors due to

complexity and Surry Sector was split off.

Any time that an aircraft is going to enter uncontrolled airspace an MSAW alert goes off

due to the fact that the MIA is listed as 128. An MSAW alert would be expected and would

be looked over. I recommend that there be an instrument approach into CYES.

Narrative: 2

I was returning from my break and began running the list to see which Certified

Professional Controller (CPC) was ready for a break. The CIC at the time asked me to open

up 15/16 D-Side, to assist the radar controller, because there was weather and icing in the

Surry sector. As I was opening up the D-side, and getting myself caught up on the traffic

situation, the radar controller announced to me that he had mistakenly descended an

aircraft below the MIA at 031 in a 035 feet shelf. The aircraft call sign was Aircraft X and it

was inbound to CYES, which is an airport in uncontrolled airspace just outside our

airspace. The weather conditions were very IFR at CYES. I am not sure why the radar

controller descended the aircraft below the MIA, since it happened right as I was sitting

down. I am thinking that he was trying to use the TAA [Terminal Arrival Area] for the

RNAV 32 approach into the neighboring airport FVE in hopes that the aircraft would get

CYES in sight and be able to proceed visually. Unfortunately, I do not know further details

about how or why the aircraft was below the MIA. The radar controller was actively

working with the CIC to remedy the situation at the time, and then the CIC quickly split

the sectors as the next controller was walking into the control room right at that time.

There is a lot of ambiguity surrounding aircraft landing at CYES, since it is in uncontrolled

airspace and is in Canada. There are no instrument approaches going into that airport, so

many times controllers are able to successfully use the approach into FVE to get the

aircraft to get CYES in sight. Unfortunately, there is no other way to allow the aircraft to

descend below 035 without using that to be able to get low enough to get the airport in

sight. It would be very helpful to have an airway that went from PQI to YYY VOR that

would allow an aircraft to descend below the 035 MIA, or better yet, an instrument

approach going into CYES airport.

Narrative: 3

I was working the CIC position for Area D performing a request for a controller when I

walked by sector 15/16 and noticed an aircraft that appeared to be flying below the MIA at

3100 feet. I asked the controller working the position what they were doing with that

aircraft. The reply from them did not seem the safest answer. Upon further discussion with

them it was decided to climb the aircraft back up to the MIA of 3500 feet. I asked the

controller to fill out a report and reported it to the Operations Manager In Charge (OMIC).

Synopsis

ZBW Controllers reported that an aircraft was descended below the Minimum IFR Altitude

in error to get it below clouds to see the airport.

ACN: 1425045 (2 of 50)

Time / Day

Date : 201702


Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Altitude.AGL.Single Value : 0

Environment

Flight Conditions : VMC

Weather Elements / Visibility.Visibility : 10

Light : Night

Ceiling.Single Value : 4000

Aircraft

Reference : X


Make Model Name : Helicopter

Crew Size.Number Of Crew : 1


Flight Plan : VFR

Mission : Ambulance

Flight Phase : Parked

Route In Use : Direct

Component

Aircraft Component : Other Documentation

Aircraft Reference : X

Problem : Improperly Operated

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Air Taxi

Function.Flight Crew : Single Pilot

Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Rotorcraft

Experience.Flight Crew.Last 90 Days : 30

Experience.Flight Crew.Type : 5500




Human Factors : Workload

Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Ground Personnel

Events


Detector.Person : Flight Crew

When Detected : Pre-flight

Result.Flight Crew : Became Reoriented

Assessments

Contributing Factors / Situations : Environment - Non Weather Related



Primary Problem : Human Factors

Narrative: 1

Captain for air ambulance was on a training flight and had put his EMS base on a 15

minute delay in case the base received a call from dispatch. Captain submitted a risk

assessment for the training flight and checked the box for 'accepts change to mission'. 5

minutes after departing on training flight, base received an air ambulance operation; pilot

returned to base, picked up crew and departed. Upon landing at the community hospital,

the Captain attempted to complete a new risk assessment, but could not get the iPad

tablet to have connectivity (rural area). Med crew came out of ER with patient, Captain

started aircraft and flew to trauma center. Captain forgot to attempt to complete the risk

assessment at that location. Entire crew flew back to base and the Captain filled out a risk

assessment for the entire patient flight upon return to base. It has been determined that

the Captain did not intend to circumnavigate the risk process and acted in good faith. The

Captain received counseling from his immediate supervisor on how to appropriately handle

this type of situation if it happens again.

Synopsis

Air ambulance helicopter pilot reported a failure to complete the flight risk assessment

process due to iPad communication problems in a rural area.

ACN: 1421777 (3 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZLA.ARTCC

State Reference : CA

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZLA





Flight Plan : VFR

Mission : Ambulance

Flight Phase : Cruise

Route In Use : None

Airspace.Special Use : R2510

Aircraft : 2

Aircraft Operator : Military

Make Model Name : Fighter



Flight Plan : VFR

Mission : Tactical


Airspace.Special Use : R2510

Person : 1

Reference : 1

Location Of Person.Facility : ZLA.ARTCC








Human Factors : Human-Machine Interface



Communication Breakdown.Party1 : ATC



Person : 2

Reference : 2




Function.Flight Crew : Pilot Flying





Experience.Flight Crew.Total : 3500









Events




Anomaly.Deviation - Procedural : Clearance



Result.Flight Crew : Requested ATC Assistance / Clarification


Assessments



Primary Problem : Procedure

Narrative: 1

Aircraft X called me and asked if restricted area R2510 was active. On my display it was

showing inactive. I told the pilot it was inactive and quickly glanced at the time it was to

change and told him that as well.

It turns out, whoever was responsible for updating the restricted areas made a mistake so

it was showing cold when in fact it was hot. The pilot called in to the front desk to

complain about being "buzzed" by fighter jets when transiting the airspace.

When I looked back over my left shoulder to find the time the restricted area was to

change, I should have taken a closer look. I would have realized that the board was

accurate. It showed the restricted area active, but I didn't look that far. I only looked at

the time It was to change. I should have paid closer attention. Although the restricted area

should have been displayed as active on my display I could have prevented the incident

with a little more awareness.

Narrative: 2

40 nm west of BWC, I contacted LA Center on Freq. to determine whether R-2510 was

"hot or cold". I was then told by the Controller that R-2510 was in fact "cold/inactive". I

was then approved to enter the restricted airspace eastbound to [my] destination. Middle

of the airspace (15nm east of BWC), I noted a formation of 4 fighter jet aircraft

performing aerobatics with smoke. Upon the jets finishing their maneuver I elected to

climb in altitude to about 3000MSL to provide more vertical separation. I then contacted

LA Center to confirm again that the airspace was "cold", he replied that it was indeed

"cold/inactive". During this time, one of the four fighter jets approached the helo to

recon/ident our aircraft. I reported the event to the controller, where he then contacted

resources on his end to further confirm the status of R-2510. The LA Center controller

came back and stated "there are schedule conflicts in the system and the airspace has

gone hot/active, but was cold when I was cleared through." The controller then provided

me with a supervisor number where I followed up after landing. It was determined that

the pilot was not at fault since he was cleared through the "thought-to-be" inactive zone.

Synopsis

ZLA Controller and Helicopter pilot reported of incorrect information which led to an

Airspace Deviation. The Controller had advised the pilot that the restricted airspace was

inactive, approved the flight through the airspace when the airspace was actually active

ACN: 1421137 (4 of 50)

Time / Day

Date : 201701


Place



Environment

Flight Conditions : Marginal


Light : Night

Aircraft

Reference : X


Make Model Name : EC135



Mission : Ambulance


Airspace.Class E : ZZZ

Person

Reference : 1









Human Factors : Training / Qualification


Events


Anomaly.Deviation - Procedural : FAR




Result.Flight Crew : Landed As Precaution

Result.Flight Crew : Diverted

Assessments




Narrative: 1

I was on a medical mission with patient on board. The forecast had shown low visibility

along the route but nothing lower than four miles. There were several small snow flurries

reported in the surrounding area but none along the route. I had checked the TAF [for the

airports involved] as well as METARS along the route of flight. I had mentioned to my crew

that we would have to stay extra vigilant with regards to low visibility on the flight. I was

under NVGs on the flight and after taking off from the referring hospital I referenced the

visibility to be greater than ten miles. About twenty five minutes into the flight I began to

notice the visibility to be decreasing. I stated to my crew that we had low visibility ahead

but was still approximately four miles (referenced by local airfield with lighted beacon and

GPS distance). Shortly after the visibility in front was less, while out of my peripheral I

could see much greater visibility. I scanned right, then left and estimated a four mile

difference in visibility. I thought it may be the windscreen fogging up so I turned on the

heating/demist. After a short time it had still not improved. It was at this time I thought

something was wrong and flipped my goggles up and turned my lip light on. Instantly I

noticed my windscreen was covered in ice! I immediately notified my crew and started a

descent while making a radio call to the local airfield of my intent to emergency descend

and land. Crew was able to see clearly out of side windows and was vigilantly looking for

obstacles. We made a safe landing and notified dispatch via satellite phone. I set the

aircraft to idle and placed the friction on the controls to exit. Once outside I noticed the ice

on the windscreen was slushy as if starting to melt. I cleared the windscreen and returned

to the cockpit. I did not notice any other icing at this time.

Once inside we initiated protocol to get the patient to proper care. Dispatch was still

looking for a facility to take the patient when I happened to look out my right window and

noticed a hospital less than a mile away. We found the hospital in our local landing zone

guide and relayed the info to dispatch. Arrangements were made with that hospital and we

were requested to re position to their helipad if possible. We had been sitting at idle for

about twenty minutes and ceilings were higher than previously per weather station. The

area was well lit from ground lights and I was able to clearly see the hospital and the cloud

levels. Conditions had changed enough so a decision was made to relocate to the hospital.

Once landed on the pad, I assisted the crew down into the hospital.

I returned to the aircraft about an hour after landing and inspected the aircraft. It was at

this time I noticed the icing on the blades. I contacted Operations to discuss the situation

and possible relocation of the aircraft. The process of running the helicopter on the ground

for a short time to try to loosen and shed the ice on the blades, then shutting down and

inspecting the blades was discussed. It was stated that if there was no ice found and icing

conditions did not exist I could possibly relocate the aircraft to the airfield. I checked in

with the crew to get an update on future logistics then returned to the aircraft about forty

minutes later. At this time I went to proceed with the ground run and noticed the

conditions had worsened. The helicopter had accumulated more ice on the structure and

the blades and I witnessed rain freezing on contact to the windscreen. I referenced

conditions at the airfield once again to find conditions subject to freezing fog and drizzle.

I cannot say I have any suggestions on how to avoid flying into that situation. Of course

hindsight is only great for learning from a situation but isn't present at the time of an

event, but I would say I would not re position to the hospital without full shut down and

complete post flight inspection if there was a chance to do it again. But at the time I used

the information available to me and deemed the weather to have improved enough to

proceed to the hospital.

Synopsis

Helicopter pilot reported encountering icing conditions and landed at the nearest airport.

ACN: 1408366 (5 of 50)

Time / Day

Date : 201612


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.TRACON : ZZZ




Flight Plan : VFR

Mission : Ambulance


Route In Use : VFR Route

Airspace.Class C : ZZZ

Aircraft : 2

Reference : Y

Make Model Name : Small Aircraft


Flight Plan : IFR

Flight Phase : Climb


Person

Reference : 1

Location Of Person.Facility : ZZZ.TRACON




Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 2.25



Events


Anomaly.Conflict : Airborne Conflict





Result.Air Traffic Control : Separated Traffic

Assessments





Narrative: 1

I was working arrival radar with light traffic. Local control was training. A medical

helicopter called me northeast of the field and needed medevac-priority handling to the

local hospital. I radar identified the aircraft and told the helicopter to maintain 2,000 feet

for traffic in the traffic pattern at ZZZ. The direct route for this helicopter to get to the

hospital would take him directly over the right downwind for Runway XY and directly over

the departure end of Runway XY. Since this was a Medevac flight, I was not going to alter

the route. Runway XY was the active runway at the time. When the helicopter was 15

miles to the northeast of ZZZ, I called tower and asked for a pointout to 2,000 feet to go

to [a local] Hospital and stated that the helicopter was medevac-priority. The local control

trainee approved the pointout.

Local control had two aircraft in the pattern at 1,500 feet for runway XY and my helicopter

had both in sight. When the pattern traffic was no factor for my helicopter, I called Local

Control to ask if I could descend my helicopter towards the hospital. It was then that I

realized an IFR aircraft just departed Runway XY on runway heading and was directly

below my helicopter. IFR aircraft depart ZZZ with an initial altitude of 3,000 feet. This IFR

aircraft would be talking to another radar controller and not me. Local control ended up

stopping the IFR aircraft, Aircraft Y, at 1,500 feet, well below the Minimum Vectoring

Altitude for the area. The trainer on Local Control asked me to put the medevac helicopter

on local's frequency so that they could solve the issue since this was all taking place right

off the departure end of the runway. I made sure that my helicopter had the aircraft in

sight and switched him to the tower frequency. I'm not exactly sure what local did to solve

this issue.

A short time later I was in the break room and the trainee walked in and tried to explain

what had happened. He told me that he had forgotten about the pointout. He had put the

aircraft in question into position on the runway behind his pattern traffic and when he had

the correct runway spacing, he gave it a take-off clearance. Throughout this whole time,

the trainer did not stop the trainee and let the situation play out making this aircraft come

within 500 feet of a medevac-priority helicopter that needed to descend.

Local control has the ability to turn datablocks yellow to signify a pointout (a memory aid).

I do not know if this was performed. Maybe I called for a pointout too early? I could have

waited a few more minutes when the helicopter was a few miles from tower's airspace and

then maybe the trainee would not have forgotten about the helicopter. The trainer needed

to pay more attention to what the trainee was doing.

Synopsis

A TRACON Controller reported a departing aircraft in conflict with an overflight helicopter

they were working.

ACN: 1405035 (6 of 50)

Time / Day

Date : 201611


Environment


Weather Elements / Visibility.Other

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Ambulance

Flight Phase : Landing

Person

Reference : 1










Events

Anomaly.Ground Event / Encounter : Object


Were Passengers Involved In Event : N



Result.Flight Crew : Regained Aircraft Control


Assessments






Narrative: 1

Was returning to base after completing patient flight with strong winds. Our base has a

very small pad and the dolly cannot be turned to face into the winds. I landed back at the

base into the wind in the grassy area to the east of the pad/dolly so the medical crew

could get out. I told them I was going to attempt to land on the dolly one time, then if it

didn't feel right, I would land back to the grassy area. After the crew got out, I hovered

over to the dolly and attempted to land with a tailwind. As I was about to touch down on

the dolly, a wind gust caused the helicopter to yaw right about 20-30 degrees and

descend. The skids hit the dolly and I immediately pulled in collective to stop the descent

and to move back to the grassy area. However, as I pulled in collective, the helicopter felt

like it was hung on something and began to feel like what I imagine dynamic rollover feels

like. I lowered the collective to stop that from happening and shut down.

After looking at the helicopter, it appears that the right rear skid got hung in the gap in

the middle of the dolly. That caused the dynamic rollover feeling. Another thing I noticed

was the dolly had shifted several feet. I don't know when that happened, before the skids

contacted the ground, or when the skids contacted the dolly.

Synopsis

EC-130 pilot reported attempting to set down on a dolly with a tailwind, but hit a skid on

the dolly and pulled the collective to ascend. Sensing what the pilot thought could be

dynamic rollover developing, he landed the helicopter. It was determined that a skid had

caught on the dolly.

ACN: 1399837 (7 of 50)

Time / Day

Date : 201611


Place



Environment

Flight Conditions : Mixed

Weather Elements / Visibility : Rain

Light : Night

Aircraft

Reference : X





Flight Plan : VFR

Mission : Ambulance



Person

Reference : 1




Function.Flight Crew : Captain




Events


Anomaly.Inflight Event / Encounter : VFR In IMC



Assessments



Narrative: 1

I checked weather before departing sending facility. Weather at sending facility was

OVC033 and 10SM. Weather at closest reporting station along route was FEW026 BKN041

and 10SM. I also checked the Helicopter Emergency Medical Services (HEMS) Tool and it

showed VFR weather conditions with some rain showers along the route. About 10 min

from receiving hospital I encountered light to moderate rain showers and visibility between

6 and 7 NM. Because of the rain it was difficult to estimate the ceiling, but I thought I was

more than 500 feet below the clouds. About 7NM west of [the hospital] I encountered

Inadvertent IMC (IIMC). It happened extremely fast. I immediately transitioned to

instruments. Once the aircraft was stable I initiated a turn to return to VMC. I maintained

my cruising altitude as I turned. The Company IIMC Procedure calls for a climb to the

MSA. The OAT indicated 3.5C and I did not want to risk climbing into icing conditions. I

knew that my cruising altitude would keep me clear of all terrain and obstacles in the area,

and I knew that there were VFR conditions behind me and to the North. Approximately 1-2

min later I returned to VMC.

I marked the "Reduced Safety Standards" Box above because I did not maintain the safety

standard of cloud clearance and visibility for the class of airspace I was in.

I was wearing Night Vision Goggles (NVGs) for the flight. It can be difficult to detect the

extent of reduced visibility conditions while using NVGs. In the future I will periodically

look under my goggles to help identify reduced visibility conditions in front of me. If I can

identify the conditions sooner than I can deviate prior to entering the IMC.

One final note. The Altitude and Heading Reference System (AHRS) 1 and the Auto Pilot

were MEL'd for this flight. This increased my workload. In the future, when items that

increase my workload are MEL'd I will increase my personal limitations for Ceiling and

Visibility.

Synopsis

Helicopter Captain reported encountering IMC conditions during a night VFR ambulance

flight. Pilot reported a turn to return to VMC and mentioned that wearing Night Vision

Goggles can make it difficult to detect reduced visibility conditions.

ACN: 1398441 (8 of 50)

Time / Day

Date : 201610


Place




Aircraft

Reference : X




Mission : Ambulance


Maintenance Status.Maintenance Deferred : N

Maintenance Status.Records Complete : Y

Maintenance Status.Released For Service : Y

Maintenance Status.Required / Correct Doc On Board : Y

Maintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Installation

Component

Aircraft Component : Main Rotor Blade


Problem : Malfunctioning

Person

Reference : 1

Location Of Person : Company


Function.Maintenance : Technician

Qualification.Maintenance : Powerplant

Qualification.Maintenance : Airframe


Human Factors : Troubleshooting

Events

Anomaly.Aircraft Equipment Problem : Less Severe


Detector.Person : Maintenance

When Detected : Routine Inspection

Result.General : Maintenance Action

Assessments


Contributing Factors / Situations : Aircraft


Narrative: 1

During Track and balance of Aircraft X, it was determined a Main Rotor (M/R) blade was

needed. Mechanic I was working with and I removed blade and replaced with the same

part number we removed. We finished track and balance and accumulated 0.3 flight time

while completing the job. Upon return to the hangar to remove tracking equipment Quality

Assurance (Mechanic) informed us that we installed the wrong Part Number.

We reviewed the paperwork from both blades and determined it was not an upgraded

blade that was installed. To upgrade the blade a Service Bulletin needed complied with

installing upgraded dampeners. We installed the upgraded dampeners on the blade in

question and corrected paperwork to reflect the change to the blade. The aircraft was then

placed back in service.

It was found that the removed blade was not properly identified, as per the Service

Bulletin, to reflect it was an upgraded blade. The Service Bulletin states that a line will be

drawn through the last two digits of the part number. In this case it would have been the

number XY. Further, the number XZ will be written in permanent marker next to the lined

out number. The removed blade did not have a line through the last two digits and the XZ

was not legible.

Synopsis

A Maintenance Technician reported that During Track and balance on a EC-135 Helicopter,

a Main Rotor blade was needed. Upgraded the existing blade per a Service Bulletin.

ACN: 1396857 (9 of 50)

Time / Day

Date : 201610


Place




Aircraft : 1

Reference : X

Aircraft Operator : Personal

Make Model Name : PA-28R Cherokee Arrow All Series

Flight Plan : None

Mission : Training


Route In Use.Other

Airspace.Class D : ZZZ


Aircraft : 2

Reference : Y


Mission : Ambulance



Person

Reference : 1

Reporter Organization : Personal



Qualification.Flight Crew : Private







Analyst Callback : Completed

Events

Anomaly.Conflict : NMAC


Miss Distance.Horizontal : 250

Miss Distance.Vertical : 50


Result.Flight Crew : Took Evasive Action

Assessments


Primary Problem : Airspace Structure

Narrative: 1

Near mid air collision.

Callback: 1

The reporter stated that he was in a practice area just outside of a class "D" airspace, with

a flight instructor doing some training. They were setting up for some flight maneuvers

when he saw a Medical Helicopter coming up on him on a collision course. He took evasive

action to avoid hitting the helicopter. The reporter stated that he believes the helicopter

pilot never saw them at all. The reporter also stated that there was never any

communication with ATC or the helicopter pilot. He said he was aware of a helicopter in

the area, but believed the helicopter was much farther north from their position.

Synopsis

A Pilot of a Piper PA28R reported while setting up for a flight maneuver they nearly

collided with a medical helicopter.

ACN: 1396205 (10 of 50)

Time / Day

Date : 201610


Place

Locale Reference.Airport : AAO.Airport

State Reference : KS

Relative Position.Distance.Nautical Miles : 8


Environment


Light : Dusk

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : AAO


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Ambulance

Nav In Use.Localizer/Glideslope/ILS : Runway 19

Flight Phase : Initial Approach


Airspace.Class E : ICT

Aircraft : 2

Reference : Y

ATC / Advisory.CTAF : AAO


Make Model Name : Skyhawk 172/Cutlass 172



Mission : Personal


Airspace.Class E : ICT

Person

Reference : 1







Qualification.Flight Crew : Air Transport Pilot (ATP)

Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Multiengine






Events



Detector.Automation : Aircraft TA




Result.General : None Reported / Taken

Assessments




Narrative: 1

I was flying left seat as pilot in command with a second in command pilot in the right seat.

We were on an IFR flight plan in VFR conditions and were receiving vectors from Wichita

[TRACON] to intercept the ILS for Runway 19 AAO which was our final destination. After

clearance to descend to 4000 and vectors to intercept the inbound course the controller

advised traffic, a primary target at our location as I was turning and descending to

intercept the localizer. Then the controller advised us to change to the advisory frequency.

At that point I was turning inbound in the course and immediately stopped the descent

while looking for the reported traffic. The SIC changed to the advisory frequency, and

established radio contact with the pilot of the C172. As that pilot was advising us that our

aircraft was passing overhead of his aircraft, I noticed the TCAS system display a target

within 300 ft of our aircraft. The SIC radioed the pilot of the C172 we were on an active

Medevac flight and asked if he would clear the area while we completed our approach and

landing into AAO. He agreed and we were able to complete our approach and landing into

AAO without further incident or delay. At the time of this incident the aircraft flight and

navigation systems were operating properly to the best of my recollection.

In my opinion the controller should have had us remain on the [TRACON] frequency to

assist us in remaining clear of that primary target.

Synopsis

Air taxi Captain reported experiencing a NMAC with a C172 on approach to the non-

Towered AAO airport.

ACN: 1392986 (11 of 50)

Time / Day

Date : 201610


Place

Locale Reference.ATC Facility : ZLC.ARTCC

State Reference : UT


Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZLC


Make Model Name : Small Transport, Low Wing, 2 Turboprop Eng



Flight Plan : IFR

Mission : Ambulance


Airspace.Class E : ZLC

Person

Reference : 1

Location Of Person.Facility : ZLC.ARTCC








Events




Anomaly.Inflight Event / Encounter : CFTT / CFIT

Detector.Automation : Air Traffic Control





Assessments


Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings




Narrative: 1

I took the sector over and didn't notice an aircraft level at 10000 feet that indicated in the

data block a climb to 17000 feet and there was a loss of separation with terrain. The

previous controller released Aircraft X to 10,000 feet. They removed the interim altitude of

10000 feet removed from the radar data block. Aircraft X checked on climbing to 10,000

feet. I plugged in for a position briefing. I took over the sector.

Aircraft X leveled at 10,000 feet while I was still "nesting" after signing on to position. The

MSAW alert went off and the aircraft requested a higher altitude. I asked him what altitude

he would like and then I realized he wasn't climbing and issued a climb to 17,000 feet as

the aircraft entered an 11000 foot Minimum Vectoring Altitude. A low altitude alert was

issued and pilot responded he had the terrain in sight. Don't remove interim altitude

before issuing new altitude. Scan faster.

Synopsis

ZLC Controller reported observing an aircraft at 10,000 feet in a MVA area designated

11,000 feet.

ACN: 1390677 (12 of 50)

Time / Day

Date : 201609


Place




Environment

Light : Night

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZZZ

Aircraft Operator : Air Carrier

Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger

Nav In Use : FMS Or FMC



Aircraft : 2

Reference : Y



Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer

Flight Plan : IFR

Mission : Ambulance



Person : 1

Reference : 1



Reporter Organization : Air Carrier











Person : 2

Reference : 2




Function.Flight Crew : First Officer

Function.Flight Crew : Pilot Not Flying









Events


Anomaly.Deviation - Track / Heading : All Types



Anomaly.Inflight Event / Encounter : Other / Unknown







Assessments





Narrative: 1

We requested a "hold for release IFR clearance", due to departing "IFR" traffic ahead of us.

Our ATC clearance was to depart a specific runway, climb to 3000 feet, and turn left to a

heading of 180. (Note: ATC radar was out of service). After given our "release for

departure", we were then given further climb altitudes. During the early climb, ATC

requested us to intercept a VOR radial. We were filed on an FMC route and needed to tune

the VOR. The First Officer (FO) mistakenly told ATC we were established on the 160 radial.

I mentioned to the FO that we were not yet established and that I would do a 140 degree

heading intercept. The FO then told ATC that we were not established on the 160 radial

and were heading to 140. Communication breakdown. ATC then said flying 140 climb to

and maintain xx altitude. We understood this to mean climb to xx altitude and maintain

140 (an intercept heading would be a normal course of action and not need a revised

altitude). When in radar contact we received further direct routing and our final altitude.

On hand off he asked us to give center a call upon arrival.

Communication breakdown/confusing instructions.

Narrative: 2

Cleared, heading 180, climb 3,000 feet. Checked in with Center, cleared to 4,000 feet.

Soon after, cleared to 9,000 feet. Medevac flight which departed before us was seen on

TCAS 2,500 feet above us and 10-12 miles ahead at our 11 o'clock. Center asked us to

intercept the 160 radial off of ZZZ. I mistakenly observed unreliable NDB needle on the

160 radial (it was 140 radial and bouncing), but quickly responded on the radio that we

were already on the ZZZ 160 radial (in error). The Captain pointed out my mistake and as

we discussed, center became concerned leveling us off and inquired about our 180

heading clearance from ZZZ Radio. More confusion followed for we didn't know if we

should continue to intercept the 160 radial or return to 180 heading. Center has us come

further right of course and continue climb. We never came closer to 5 miles of the

medevac aircraft, yet 15-20 minutes later center gave us a phone number to contact citing

a possible investigation into pilot navigation error/discrepancy. Following debrief and

contact with center supervisor, we were told that a quality control check was being

pursued.

Lack of good communication techniques with my Captain and ATC following poor

situational awareness.

Synopsis

Air carrier flight crew described the confusion resulting from the First Officer mistakenly

confirming aircraft established on a VOR radial, instead stating the aircraft heading which

confused ATC.

ACN: 1381828 (13 of 50)

Time / Day

Date : 201608


Place





Environment


Weather Elements / Visibility : Turbulence


Light : Night


Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ





Flight Plan : VFR

Mission : Ambulance




Person

Reference : 1
















Events


Anomaly.Inflight Event / Encounter : CFTT / CFIT

Detector.Automation : Aircraft Terrain Warning

Detector.Automation : Aircraft TA


Result.Flight Crew : FLC complied w / Automation / Advisory

Assessments



Primary Problem : Ambiguous

Narrative: 1

While returning to base from a patient transfer I encountered reduced ceilings enroute.

The ceiling was consistent at about 2000 feet AGL. There was rising terrain ahead. I

selected an altitude that would allow me to cross the high ground an equal distance from

the terrain and the ceiling. The terrain was not level, as I crossed the apex of the pass the

terrain alerting system in the aircraft announced minimums several times. My focus was

outside the aircraft but when I did glance at the radar altitude I noted that I had gone

below 500 feet AGL several times. This terrain crossing lasted a few minutes. I could have

minimized the number of terrain alerts but chose to stay in a stable flight profile. The

visibility was very good and the illumination from cultural lighting was more than sufficient

to identify obstacles and prevent CFIT.

I am required to maintain 500 AGL at night per the FARs. My decision to stay an equal

distance from the clouds and the terrain put me below minimums. I felt that the greatest

risk during this portion of the flight was an Inadvertent IMC (IIMC) event. Based on the

visibility and the illumination I felt that a lower altitude guaranteeing cloud clearance was

the most conservative approach.

Landing the aircraft was always an option. What I did not want to do was climb the aircraft

closer to the clouds to satisfy the system. The risk was an IIMC event, the terrain and

obstacles were clearly illuminated.

Since Night Vision Goggles (NVG) are in such wide use today there should be a change

that allows pilots to fly at lower altitudes with NVGs. We are able to reduce our weather

minimums but not our in route minimum altitude.

Synopsis

A helicopter pilot reported difficulty maintaining the FAR required altitude above terrain

due to a lowering weather ceiling and rising terrain.

ACN: 1375426 (14 of 50)

Time / Day

Date : 201607


Place

Locale Reference.Airport : ZZZ1.Airport


Environment



Light : Daylight


Aircraft

Reference : X


Make Model Name : King Air C90 E90


Flight Plan : None

Mission : Ambulance



Airspace.Class G : ZZZ1

Person

Reference : 1













Human Factors : Fatigue


Events



Anomaly.Ground Incursion : Runway


When Detected : Aircraft In Service At Gate


Assessments



Narrative: 1

My crew was dispatched from ZZZ to ZZZ1 at which point we were to pick up a patient in

ZZZ1 and take them to a better care facility in ZZZ2. I was taking a safety nap when

dispatch came in, because of sleep inertia I assumed that we were leaving from ZZZ to

ZZZ2, which is our routine flight and because of this I took my time filing flight plans and

even took a shower because our medics usually take about 30 minutes packaging the

patient to bring them to the plane. One of the medics came in the crew quarters and ask if

I was ready for departure, it was at this point that I realized that I had sleep inertia and

had planned the flight completely wrong. I hurriedly exited the crew quarters and entered

the plane, took off to ZZZ1 without checking NOTAMs. The Runway was NOTAMed closed

for resurfacing, I did not notice the yellow X off the end of the runway because it was

laying in weeds which blocked my view of it from a lateral angle. There were no workers or

equipment present on the runway. I spoke with the Airport Manager and he gave me

permission to depart ZZZ1.

Synopsis

C90 Captain reported being awakened from sleep to fly a medevac flight but not

comprehending the assignment due to fatigue. When informed that the flight is ready to

depart he quickly jumped in the aircraft without checking NOTAMs. After landing he

learned that the airport was closed for runway resurfacing.

ACN: 1372997 (15 of 50)

Time / Day

Date : 201607


Place

Locale Reference.Airport : RLD.Airport

State Reference : WA


Environment


Light : Dusk

Aircraft : 1

Reference : X

ATC / Advisory.CTAF : RLD


Make Model Name : Light Transport, Low Wing, 2 Turbojet Eng



Flight Plan : VFR

Mission : Ambulance



Aircraft : 2

Reference : Y


Make Model Name : Small Aircraft



Mission : Personal

Flight Phase : Takeoff

Person : 1

Reference : 1















Analyst Callback : Attempted

Person : 2

Reference : 2















Analyst Callback : Attempted

Events

Anomaly.Conflict : Ground Conflict, Critical







Assessments



Narrative: 1

We were landing on runway 19 [which is] shorter and narrower than average. We had

reported the airport in sight about 15 miles out on an IFR flight plan and received the

visual. Runway 19 is the calm wind runway and also the runway with the least amount of

slope. The winds were calm and the time of day was sunset. At about 8 miles out we

canceled IFR and switched over to advisory frequency. The PNF made radio calls on CTAF.

I was flying and concentrating rather intently on Vref and the proper angle to be flown for

a short field landing. I touched down about 1,000 feet down the runway and almost

immediately spotted a small airplane moving at a high rate of speed from my right to my

left on runway 8. The closure rate was very fast and I applied pressure on the right rudder

to veer as safely as possible to my right and miss the small aircraft. We missed each other

by about 75 feet right at the intersecting point of the two runways. Left rudder was briskly

applied to correct the airplane back to the center of the runway. More radio calls were

made after we observed the airplane continue his takeoff run and return for a landing. No

answers were received. The sun was setting on our right side and obscured the view of the

approach end of runway 8.

Corrective Action: Our industry has progressed far too much in the last 25 years to not

require a radio for all aircraft that use the terminal area of a specific size of airport. This

particular airport has multiple approaches and is located within 5 miles of a class D airport.

Narrative: 2

I believe the contributing factors to this near collision were crossing runways at an

uncontrolled airport, the sun obstructing our view to the west, and an aircraft that was not

making position reports on CTAF. In my opinion, in the technological age in which we live,

all aircraft should be mandated to have an operational radio and to participate in position

reports on CTAF at non controlled airports, especially with instrument approaches. Had the

other pilot been on the radio, this event would never have happened.

Synopsis

Air ambulance flight crew landing at RLD reported a near collision with another aircraft

taking off on an intersecting runway. The other aircraft reportedly was not communicating

on CTAF frequency.

ACN: 1368320 (16 of 50)

Time / Day

Date : 201606


Place

Locale Reference.ATC Facility : GEG.TRACON

State Reference : WA


Environment


Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.TRACON : GEG


Make Model Name : Small Transport



Flight Plan : VFR

Mission : Ambulance



Airspace.Class D : SFF

Aircraft : 2

Reference : Y

ATC / Advisory.Tower : GEG


Make Model Name : Medium Large Transport



Flight Plan : IFR

Mission : Passenger


Route In Use.Other

Airspace.Class C : GEG

Person

Reference : 1

Location Of Person.Facility : GEG.TRACON


Function.Air Traffic Control : Trainee

Function.Air Traffic Control : Departure

Qualification.Air Traffic Control : Developmental




Events






Result.Flight Crew : FLC complied w / Automation / Advisory

Result.Flight Crew : Executed Go Around / Missed Approach



Assessments





Narrative: 1

I am currently a CPC-IT (Controller In Training) and was training on radar. I had just

taken the position from a previous controller and saw that Aircraft X was departing off SFF

on a heading of 300 restricted at or below 3500 feet(this is a built in procedure for VFR

aircraft coming off SFF). I was briefed that Aircraft Y was cleared on the RNAV Z RWY 21

approach and had been switched to the tower. I recognized that the two aircraft were

going to be a conflict and was trying to formulate a solution. Aircraft Y was descending out

of approximately 4500 feet when Aircraft X checked on level at 3500 feet. At this point the

two aircraft were pointed right at each other approximately 3 miles apart. I knew aircraft

on the RNAV Z RWY 21 approach were allowed to descend to 3500 which is the exact

altitude that Aircraft X was restricted at. When Aircraft X checked on I told him altitude

your discretion and to proceed on course, followed by a traffic call. My initial plan was to

have Aircraft X climb above the descending Aircraft Y, then issue a northerly heading if

necessary. My instructor keyed over me at that point, gave a traffic alert and told Aircraft

X to fly northbound. The tower then called saying Aircraft Y was responding to a TCAS

alert and was coming back to radar for resequencing. Aircraft X continued on course below

Aircraft Y and the session continued without further incident.

Foremost, it was poor control judgment on my part to not issue an immediate turn to

Aircraft X and to think that an altitude swap alone was going to resolve the situation. I was

slow to see how quickly the situation was developing and should have been quicker to

react. However, I do think that the letter of agreement (LOA) pertaining to automatic VFR

releases between SFF and GEG is flawed. The procedure calls for all VFR aircraft whose

departure routes will take them towards GEG Class C surface area to either fly heading

300 at or below 3500 feet or remain south of the interstate at or below 3500 feet. My two

main concerns with this procedure relate to aircraft separation and vectors below the

minimum vectoring altitude. VFR aircraft departing SFF on a heading of 300 at or below

3500 points them directly at GEG's final. Typically aircraft on the visual approach to RWY

21 and other approach procedures pass over these VFR aircraft at 4000. However, outside

of issuing an immediate control instruction to avoid a conflict, there is no ensured

separation with this procedure. This lack of separation can also happen with VFR aircraft

departing south of the interstate at or below 3500 feet. It is especially concerning to me

that aircraft on the RNAV Z RWY 21 approach can descend to 3500 feet on the base turn,

the exact altitude that a VFR aircraft coming off of SFF can be at.

I also think the LOA is contradictory to the 7110.65 relating to vectors below the MVA

(Minimum Vectoring Altitude). In the 7110.65 per 5-6-1 it makes it very clear that a VFR

aircraft cannot be assigned a heading and altitude below the MVA (with certain exceptions

that either don't apply in this case or have not been made clear to me). All of our MVAs in

the area are above 3500 ft MSL which make me unsure of how this LOA is meeting the

7110.65 requirement.

This incident definitely drove home the point that imminent traffic situations can develop

very quickly and at any time. In future situations I will take more evasive action and be

more vigilant to avoid making a similar mistake. I think departing VFR aircraft either to the

NE or SE would be a better procedure for SFF. However, I know there is higher terrain

east of SFF so this might not be possible. The other idea would be for SFF to call for VFR

releases. I definitely think this procedure should be revisited to avoid conflicts with future

aircraft.

Synopsis

An Air Traffic Controller Trainee reported failing to take sufficient action to keep a VFR

aircraft away from an IFR aircraft executing an approach to an airport. The Trainee

Controller mistakenly believed he could not vector the VFR aircraft below the MVA.

ACN: 1364396 (17 of 50)

Time / Day

Date : 201606


Place

Locale Reference.ATC Facility : CHS.Tower

State Reference : SC

Aircraft : 1

Reference : X

ATC / Advisory.Tower : CHS


Make Model Name : Military Transport

Flight Plan : IFR

Flight Phase : Final Approach

Airspace.Class C : CHS

Aircraft : 2

Reference : Y


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear

Flight Plan : VFR


Route In Use : None


Aircraft : 3

Reference : Z





Flight Plan : IFR

Mission : Ambulance



Person

Reference : 1

Location Of Person.Facility : CHS.Tower


Function.Air Traffic Control : Local








Events




Anomaly.Inflight Event / Encounter : Wake Vortex Encounter




Assessments




Narrative: 1

TRACON called to coordinate the request of Aircraft X to fly TACAN 03, circle overhead

("the entire airfield") to Runway 33, then entry into the Tower pattern. I was given "your

control in the tower pattern" from TRACON. The data tag conflicted with the information

from verbal coordination, so I reattempted coordination with TRACON to verify the

situation. The Front Line Manager (FLM) called on the telephone to straighten that out and

to give me other airfield information. West radar then called and restated the situation,

"Aircraft X, TACAN RY03, circle 33 with the overfly. Aircraft Y will be straight in to follow

Aircraft X". Aircraft X was shipped to me at about 7 NM final RY03 and stated the request

to overfly the airport for RY33. Clearance was issued. When Aircraft X was short final, she

requested to enter initial on the missed approach. I told her that we will be able to

accommodate that request. When Aircraft X was over the intersection, Aircraft Y checked

onto my frequency straight into RY33 (10 NM final). I asked if he had Aircraft X in sight

and the answer was no. While I started to go through my options, I asked again if Aircraft

Y had the Aircraft X in sight, turning onto the downwind for RY33. He said yes. I then

instructed Aircraft Y to "Maneuver as necessary to follow Aircraft X, caution wake

turbulence for Aircraft X, RY33 cleared to land". When Aircraft X was turning base I issued

the same instructions (360, "s" turns, whatever he needed).

When Aircraft X went around, I adjusted the data block of the Aircraft X to reflect initial

RY03, full stop in accordance with CHS7110. I then adjusted the flight paths of Aircraft Y

and a corporate jet to make a hole for Aircraft X. After Aircraft X entered initial RY03,

TRACON called for a point out on Aircraft Z, a helicopter to a local hospital. I asked if the

helicopter was a lifeguard (priority) since he was enroute to a hospital and the data tag

failed to reflect that information. The answer was yes. I approved the point out and fixed

the data tag for West Radar/TRACON. I was watching to see how the situation was

working between Aircraft X and the helicopter, and between Aircraft X and the gap that I

had built with the RY33 arrivals. I saw that Aircraft X would be descending onto the

helicopter, losing wake turbulence separation, so I asked Aircraft X to go around and

reenter initial. She complied. She flew out bound 5-7 NM to reenter when West Radar

called to ask what she was doing, I told him. An aircraft was over Aircraft X at 3000 for

RY03. West radar resequenced the arrival onto RY33 and I fixed that data tag.

Synopsis

CHS Tower Controller reported of a problem with traffic into the airport. The pattern traffic

was working until the reporter was given a point out on a Lifeguard aircraft which caused

the pattern to be disrupted and caused a wake turbulence problem.

ACN: 1361710 (18 of 50)

Time / Day

Date : 201606


Place



Environment


Weather Elements / Visibility : Thunderstorm

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ





Mission : Ambulance


Airspace.Class B : ZZZ

Person

Reference : 1












Events





Assessments




Narrative: 1

Received a flight request at about XA:30. I built the risk assessment on the iPad and didn't

push send because I was waiting for our com center to send the flight to ZZZ. I went and

talked with the flight crew to make sure that they would be comfortable with the

thunderstorms out west and go over the risk assessment with them. They ended up being

fine with the flight and I accepted it at XA:35. As I was walking through the com center I

was told that there was a drone operating in one of the parking lots next to helipad and

that the com center was going to call to have them stop operations. This was the biggest

distraction for me. I knew nothing about any scheduled drone activity. When I lifted off I

called the control tower and asked if they had been informed that there was a drone

operating in their airspace. They also were unaware of the drone. The control tower said

they would call the state police. Once I was clear of the hospital and no longer worried

about the drone I realized I forgot to push send on the iPad for my risk assessment and

wait for approval. I had my com center call and let them know. [Control] told them I

would need to call in. Once I landed at the scene I shut down and called. [Control] got the

flight approved and we finished the fight.

The only thing I would say is maybe have my com center ask if I have sent in my risk

assessment when I'm walking out the door. But this is not their responsibility and the fault

is mine 100%. I got distracted and forgot to push send and wait for the approval from

[Control].

Synopsis

Medevac helicopter pilot reported being advised of a UAV which was operating in the

vicinity of his proposed flight path. This information caused him to be distracted which

resulted in his non-compliance with company risk assessment procedures.

ACN: 1359784 (19 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Daylight


Aircraft

Reference : X


Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model



Flight Plan : VFR

Mission : Ambulance



Component

Aircraft Component : Tablet


Problem : Design

Person

Reference : 1















Communication Breakdown.Party2 : Dispatch

Events




Detector.Person : Dispatch



Assessments





Primary Problem : Aircraft

Narrative: 1

I put my risk [assessment] in and went about preparing for flight, I went up to the

aircraft, did my walk around, came in to the cockpit, the iPad dinged like it does with

every flight when OCC (Operations Control Center) approves it. I looked quickly at the

screen and with the glare thought it was approved, it turned out OCC had not approved

the mission but pinged me back to discuss the weather front to my west. I was aware of

the front but in the time I had gone up to the helipad it had made a significant update on

radar and moved closer. I took off with what I thought was an approved brief instead it

was a call from OCC. I let dispatch know I was landing assured and they said call from

OCC. When I did we discussed that the tone for approval and every notification is the

same and the IT department was working on a change so it would be different. Flight was

completed with no problems.

I discussed it with the OCC personnel and a change to the approval ding on the IPad and

other notifications is already in the works. Additionally I will discuss this with my base

pilots and at the upcoming safety meeting to help make other pilots aware of the possible

results of submitting a risk and specifically looking and ensuring the mission is approved

not call OCC.

Synopsis

An EMS helicopter pilot reported hearing an iPad notification sound which he thought

indicated Dispatch's mission approval after his risk assessment. In fact, Dispatch wanted

to discuss weather. A distinctive Dispatch approval notification "ding" was discussed as a

solution.

ACN: 1356741 (20 of 50)

Time / Day

Date : 201605


Place




Environment


Light : Night

Aircraft

Reference : X



Mission : Ambulance

Flight Phase : Initial Climb

Component

Aircraft Component : Turbine Engine



Person

Reference : 1















Communication Breakdown.Party2 : Ground Personnel

Events




Were Passengers Involved In Event : Y




Result.Flight Crew : Rejected Takeoff


Result.Aircraft : Aircraft Damaged

Assessments






Narrative: 1

Last night of my shift, landed for patient pickup at XA:56 with flight nurses on board. Upon

landing, the nurses notified me that they had just been contacted by EMS on the VHF radio

and that the patient had expired and we were no longer needed. Everyone remained

seated and belted as we discussed that we hadn't heard anything yet from Operations and

about how best to contact them. The crew members tried and were able to receive them

on the ground and confirmed cancellation. This all took place quickly. I confirmed with

crew that they were ready to lift and began to pull pitch when I noticed the Yellow Caution

Light start to flash. Having just reached a low hover, I saw that only one engine was in fly

and set the aircraft back down. I then realized that as a matter of habit, I must have

begun to shut down on landing and only placed engine #2 in idle as we were being notified

of cancellation.

After full skids down there were no caution, warning lights or exceedances. I returned

engine #2 to fly, and stopped to verify that there was no exceedance. I verified caution

panel and instruments and continued with departure and return flight. After landing at

base, upon placing engines in idle and after shut down, there were no exceedances on

caution advisory display.

After fueling the aircraft at base I had the master battery on to check fuel level and

decided to double check the CAD. After start up, FADEC #1 illuminated an "Engine Exceed"

light on the number one engine. The discrepancy was noted in the aircraft log book, duty

mechanic responded and aircraft was placed out of service with dispatch. The aircraft

being flown was our backup EC-135.

Obviously, I am solely at fault for not exercising better situational awareness. This

situation could have been avoided if I had not interrupted the process of going from flight

to idle, something I don't think I have ever done before, and then re-initiated a complete

pre-takeoff check.

Synopsis

An EC-135 EMS pilot landed for patient pickup, but because the patient had expired, the

flight returned to base. The pilot started his takeoff with an engine in idle, but landed

immediately, returned the engine to fly and departed. Upon arrival he discovered a CAD

FADEC #1 "ENGINE EXCEED" alert so the aircraft was removed from service.

ACN: 1354660 (21 of 50)

Time / Day

Date : 201605


Place

Locale Reference.ATC Facility : ZMP.ARTCC

State Reference : MN


Aircraft : 1

Reference : X

ATC / Advisory.Center : ZMP




Flight Plan : IFR

Mission : Ambulance



Airspace.Class A : ZMP

Aircraft : 2

Reference : Y

ATC / Advisory.Center : ZMP


Make Model Name : Military

Mission : Tactical


Airspace.Class A : ZMP

Airspace.Special Use : POWDER RIVER 4

Person : 1

Reference : 1

Location Of Person.Facility : ZMP.ARTCC








Person : 2

Reference : 2







Person : 3

Reference : 3








Events





Result.Flight Crew : Exited Penetrated Airspace




Assessments


Contributing Factors / Situations : Chart Or Publication

Contributing Factors / Situations : Manuals



Narrative: 1

Aircraft X was a departure southbound requesting FL190. Powder River 4 ATCAA was

active from 15000 feet to FL260. Aircraft Y was in the airspace. I received a call from the

ZLC supervisor stating the sector (20 or 23) had asked their controller to see if the

airspace could be recalled. I went to the area to see what was happening and Aircraft X

was at 14500 feet flying under the western boundary below the airspace. I confirmed with

the ZLC supervisor that we would like it recalled FL190 and below to accommodate the

medevac aircraft. The sector 20 controller called me later and said they were talking to

Aircraft Y and had issued him FL200 and above and the medevac was going to use the

airspace. I told her we did not control the airspace and it was hot until it was released. I

observed Aircraft X within 1-2 miles of the PRC4 airspace boundary at FL190 prior to the

airspace being recalled. The ZLC supervisor called to release the airspace and felt the

medevac was too close to PRC4 prior to that. I agreed and stated I would file an

Mandatory Occurrence Report. Proper recall procedures were not followed, and Aircraft X

entered the protected airspace of PR4 prior to official airspace recall.

I was the Operation Manager on the midshift. The Traffic Management Unit (TMU) had

gone home so I also had that position. The supervisor in Area 4 asked if she could plug in

because she had two controllers going home. There were two midshift controllers who had

signed in and not worked, and 1 controller who had been on break for 1:45. I told her the

midshift controllers could work. There is a common practice in this area that the midshifts

do not work when they come in. So the first one does not plug in for two hours, and the

other one closer to 5 hours. Several of the supervisors enable this by plugging in instead

of doing their job of supervising the area. She said she needed time anyway, so I allowed

it. I believe she is the one who initiated the recall procedures sector to sector. When the

ZLC supervisor called I had no idea what he was talking about since the proper

coordination of having the sup (now me) call TMU (also me) and coordinated through the

ZLC TMU to recall the airspace. This airspace affects 3 centers, and ZLC is the focal to deal

with the scheduling agency. Also, this airspace goes hot on the requested times, not real

time when aircraft are cleared into the airspace. In this case, Aircraft Y was in the

airspace, so that isn't relevant. After the supervisor in Area 4, currently working sector 20,

had talked to Aircraft Y and had him maintain an altitude above the medevac, there was a

belief they could use this airspace. We have no control or coordination of this airspace and

that is incorrect.

Issues that lead to this event:

Recall procedures are to coordinate through TMU. I was staffing TMU and no request was

made. I was staffing Area 4 OS and no request was made. Area 4 OS was in the sector.

Common practice to not make the mids plug in. Mid shifters had been here and hadn't

worked. Another employee had been on break for over two hours and the sup was

working.

The supervisor should not have been plugged in. This would have allowed proper

supervision of the area and proper coordination procedures for the recall of the airspace in

a timely manner. In this instance, the supervisor, working sector 20, either didn't know or

didn't care that she couldn't use that airspace so I highly doubt the airspace deviation

would have been avoided.

Narrative: 2

Powder River 4 MOA/ATCAA was active from 15000 feet to FL260. Aircraft X departed

requesting FL190 for the final. I climbed them to 14000 feet on the departure clearance

and after I radar identified them I asked if they wanted a small turn to avoid the airspace

or if they wanted to go underneath at 14500. They mentioned the airspace could be

recalled for them because they were a medevac. I told my sup who called ZLC. Shortly

thereafter Aircraft Y checked on with the sector above my airspace (sector 20). Sector 20

owns FL240 and above in that area. Sector 20 asked the aircraft if they were able to

maintain at or above FL200 in the ATCAA. They replied in the affirmative. Sector 20 asked

Aircraft Y if they were the only aircraft in Powder River 4, and they said yes. Sector 20 and

myself are the only sectors that are able to approve entry into Powder River 4. I climbed

Aircraft X to FL190 at that time and then sector 20 received a call from someone, I don't

know whom. Saying the MOA/ATCAA was still active from 15000 feet to FL260. I turned

Aircraft X to the right but was already within 3 NM of the ATCAA boundary. After a few

minutes ZLC called sector 20 and told them the ATCAA was ours FL190 and below, I then

cleared Aircraft X direct [destination airport] at that time.

Powder River Training complex has numerous ATCAAs and MOAs, all of which are

scheduled to go active at a certain time whether aircraft are in them or not. They also stay

active long after aircraft have left. Many times controllers will not get a 10 minute warning

that the airspace is going active. The active times are listed on the TV on the wall, but if

workload increased it can catch you off guard. It does not go active the same way as all of

the other MOAs or ATCAAs in ZMP area 4.

Recommendations:

10 minute warning of Powder River ATCAAs/MOAs going active.

Airspace goes cold the moment participating aircraft exit.

Recalling the airspace should be easier than a long line of phone calls that takes 10 to 15

minutes. Recalling the airspace should be as easy as asking the participating aircraft to

maintain certain altitudes, with their acceptance it is available for Medevacs, aircraft

deviations, emergencies etc.

Narrative: 3

Aircraft X was a Medevac aircraft that departed enroute to an airport [to the south]. The

aircraft's route took it through active military airspace that is wholly contained in our

airspace but control of that airspace is the responsibility of ZLC. The airspace was active

from 15000 feet to FL260 (my sector was from FL240 and up). The controller prior to me

had told me that Aircraft Y was in the airspace and was probably going to exit the airspace

early. I could see Aircraft Y in the airspace orbiting at FL240. The medevac departed and

wanted to stay on course and climb to FL190. I initiated the call to the ZLC controller to

see if we could recall part of the airspace, (from FL190 and down), to accommodate the

medevac aircraft. The controller told me he would call his military and get back to me.

After at least 5 minutes, Aircraft Y called me and said he would like to exit the airspace in

about 10 minutes. At that time, I asked Aircraft Y if he could maintain the block FL200-

FL260. Aircraft Y replied that he could, so I assigned it. I asked him if he was the only

aircraft in the airspace and he said he was. I called the Operations Manager to relay this

information and was told that we still needed to have ZLC release it, (which I knew). I

then saw that the controller who was working the medevac had started to climb the

aircraft. I let the controller know that we still didn't have control of the airspace and he

should turn the aircraft. I think about a minute or two later, (maybe less), the ZLC

controller called me and said we had control of the airspace from FL190 and down. Shortly

after this, the Operations Manager came down and advised us that we had control of the

airspace. I notified him the ZLC had already called me prior to him coming down to the

area to let us know. I was not working the medevac aircraft but I believe that he was

probably closer to the airspace than the required mileage. To my knowledge, we are

supposed to be able to recall this airspace within 5 minutes time, which I do not believe

occurred.

I don't believe that it is very efficient to have a military airspace that is wholly contained in

our area to be controlled by another facility. I was talking to the aircraft that was delaying

in the airspace and yet we needed to wait for approval from the other center before we

could recall part of the airspace. Also, to my knowledge, the airspace was allowed to time

out about 45 minutes later instead of recalling the airspace when the aircraft was clear. I

feel that this could make other aircraft (besides the medevac) get turned large distances

out of their way for an airspace that isn't being used. I don't feel that this is a good way to

treat our users. I have seen medevac aircraft have the same issue (affecting their

route/altitude) before.

Synopsis

Several ATC Controllers reported that an aircraft was allowed to get less than the required

distance from an active ATC Assigned Airspace. A Controller had used incorrect procedures

to allow the aircraft to proceed toward the airspace.

ACN: 1351591 (22 of 50)

Time / Day

Date : 201605


Place

Locale Reference.ATC Facility : ZLA.ARTCC



Environment


Light : Daylight

Aircraft : 1

Reference : X



Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger



Airspace.Class A : ZLA

Aircraft : 2

Reference : Y






Flight Plan : IFR

Mission : Ambulance


Airspace.Class A : ZLA

Person : 1

Reference : 1

Location Of Person.Facility : ZLA.ARTCC









Person : 2

Reference : 2














Person : 3

Reference : 3













Person : 4

Reference : 4



















Person : 5

Reference : 5

Location Of Person.Aircraft : Y


















Events


Anomaly.Deviation - Altitude : Excursion From Assigned Altitude


Detector.Automation : Aircraft RA







Assessments




Narrative: 1

An Air Taxi checked in north bound climbing to FL230 out of approximately FL180. I

climbed the aircraft to FL270 and received the read-back. I stopped them at FL270

because there was traffic west bound at FL280. When the Air Taxi was approaching BLH, I

called traffic to both Air Carrier and the Air Taxi, clearly stating that the Air Taxi could

expect higher when clear of that traffic. From watching the Falcon I saw that the Air Taxi

climbed from FL265 to FL275 busting their assigned altitude. At the same time, another

aircraft was checking in on the far left side of my radar scope, so I did not notice the

altitude violation. The Air Taxi climbed to FL279 and asked for higher. I then again recalled

the traffic and during the transmission I realized that the Air Taxi was now at FL279 and

not their assigned FL270. I quickly keyed up again and climbed the Air Taxi to their

requested final altitude of FL370 with an expeditious rate. Then I descended the Air Carrier

to FL260 to regain separation and assigned an expeditious rate. At this point the aircraft

were about 8 miles apart, but converging. During this time the Air Taxi began to descend

because I am guessing at some point they realized their mistake. It probably happened

sooner, but there is a delay in the radar data, so I was working with old information. Very

shortly the Air Carrier stated they were in an RA climb. I then told the Air Taxi to

immediately turn 30 degrees to the left. I clearly lost my 5 mile/1000 ft separation

requirement and at this point I was just trying to keep the aircraft safe and prevent a

collision. From the information I gathered from the Falcon, at the closest point the aircraft

were about a mile and 100ft apart. I did not give the Air Taxi the brasher because I was

quite shaken at this point, but the next controller did.

If the Air Taxi would have just followed instructions to begin with, none of this would have

happened.

Narrative: 2

Level at FL280, ATC advised us that we had traffic, an Air Taxi at 10 o'clock and that he

was restricted below us to FL270. I heard the Controller advise an Air Taxi that he had

traffic at 1 o'clock, an Air Carrier at FL280, and to expect higher when clear. Shortly

afterward I heard the Air Taxi request a higher altitude. The Controller responded with "I

see you blew your altitude, climb and maintain FL370". The controller then cleared the Air

Taxi to "expedite to FL370". We then received a clearance to descend to FL260 and to

"expedite all the way down". I selected FL260 in the altitude window and selected Level

Change to ensure an idle descent. I also noted traffic low to my left on the TCAS that was

less than 1,000 feet below us and climbing in very close proximity to us.

I asked my First Officer (FO) to confirm our descent clearance with ATC and received a

TCAS TA almost immediately followed by a "CLIMB CLIMB CLIMB" RA. I immediately

disconnected the autopilot and auto throttles and complied with the TCAS cues, and my FO

advised ATC we were complying with a TCAS RA and climbing. The controller then issued

an immediate 30 degree left turn to the Air Taxi. By now it was pretty hard to not see the

Air Taxi streaking across our wind screen climbing like a homesick angel. TCAS finally

declared "Clear of Conflict", received clearance to maintain FL280 and proceeded without

further incident.

I believe that in this case the TCAS placed us in closer proximity to the Air Taxi. Once we

had visual contact with the traffic it was obvious that we weren't even close to out-

climbing it, and even though we were following a TCAS climb directive, the other aircraft

out-climbing us is what cleared the conflict.

Narrative: 3

[Report narrative contained no additional information.]

Narrative: 4

The flight crew's understanding of clearance at time of first TCAS TA was climb to FL370,

direct destination and the Autopilot was maintaining flight control of the aircraft. As we

climbed thru approx. FL250, LAX Center asked if we had an air carrier traffic in sight

approximately 15 miles north east at FL280. We responded that the aircraft is in sight. At

that point two things external to this event happened 1) the cabin temperature became

very warm and 2) the navigation computer indicated not enough fuel to make destination.

Since the aircraft was known to be full of fuel this became a secondary concern. The

patient however, was very temperature sensitive and I (the PIC) went off the radio

momentarily to deal with this problem. After finishing with temperature issue (approx 1-2

min) and as I was coming back onto the radio we got a TA (Traffic, Traffic) alert, we were

thru approx. 27,000 feet MSL and climbing approximately 1,800 FPM, in my opinion we

would not adequately clear the traffic who at this time was approximately 8 or 9 miles way

so I stopped the climb (by the time the climb stopped we at approx. 27,900 MSL) and

initiated a shallow descent. The TCAS TA resolved as we started a descent. My First officer

(SIC) transmits: "..requests a higher altitude", he probably should have advised center

about the TA descent, instead of the subsequent need for to continue the climb to a higher

altitude, but what he said is what he said. As I descended the controller said: "Looks like

you busted your altitude" a moment later the controller asked "Say your altitude" as the

question was asked we were leveling at appropriately 27,200, and the First Officer (SIC)

responded "..is leveling FL270", a very short time later the controller issues a climb

clearance: "..expedite your climb to FL370" which we read back. A expedited climb was

initiated (an expedited rate of climb at this altitude, when establish, would be about 3,000

FPM) as the climb was established and approximately 27,600 MSL we got a "climb RA". I

went immediately into emergency climb mode (max power, high angle of attack,

converting any excess energy into altitude) resulting climb rate approximately 4,500 FPM.

The TCAS RA resolved about 20 seconds later resulting in the two aircraft separated by

approximately 2 to 300 feet vertically and about 1 mile horizontal separation. The time

duration of this entire event was approximately 3 minutes.

It appeared that the air carrier also had a TCAS climb command RA which I feel extended

the resolution time somewhat. In retrospect and in my opinion the controller should not

have issued us the expedited climb clearance which caused us to climb into the RA in the

first place, after the initial TCAS TA was resolved.

Narrative: 5


Synopsis

ZLA Controller and two flight crews describe a serious airborne conflict which developed

after an air taxi inexplicably climbed from their assigned FL270 into an air carrier at FL280.

The aircraft at their closest were 100 feet vertically and about 1 mile horizontally.

ACN: 1350521 (23 of 50)

Time / Day

Date : 201604


Place



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Ambulance



Person

Reference : 1













Events






Assessments



Narrative: 1

Dispatched to ZZZ for patient pickup for an inter-facility hospital transfer. I was

monitoring the ZZZ Unicom frequency at least 30 nm out. I made an inbound call at

approx. 10 nm out and another one at approximately 4 nm out. No response was heard

from any aircraft. Upon arrival at the airport and on short final for landing to the ramp for

shutdown, I heard someone on a handheld radio say "Helicopter approaching, we have

jumpers in the air". My crewmember up front and I scanned the area and saw one single

jumper at approximately 1500 AGL with the chute deployed. It was not in a position to be

a hazard to our final approach so I continued on short final and landed to the ramp and

shutdown. [A military organization] was conducting jump operations in a C-130 at the

time of our arrival. At no time from approximately 30-40 nm out until arrival did I ever

hear any calls on Unicom from a C-130 and did not hear any "jumpers away" calls. In

addition there was another helicopter that approached from the same direction and landed

a few minutes after I did. I talked to him and he said he never heard any "jumpers away"

call. I also heard other small fixed-wing aircraft on the Unicom as I was approaching. The

first call I heard regarding any jump operations was from the person on the handheld

radio on short final. After shutdown, a representative from the [military] unit came and

talked to me. I explained to him what I explained above. He mentioned he would have to

submit a report to the FAA since there was a jumper at 1500 AGL with the chute deployed.

After the medcrew returned in the ground ambulance we loaded the patient. The jump

operations had ceased at that time and we departed without incident and completed our

medical mission.

In addition to monitoring the Unicom frequency and making the inbound position reports

and calls as I did, I would query on Unicom if there were any aircraft in the area and

specifically any jump aircraft in the area.

Synopsis

EC135 medevac pilot reported encountering unannounced jumpers in the air on arrival to

an uncontrolled airport.

ACN: 1350154 (24 of 50)

Time / Day

Date : 201604


Place


Aircraft

Reference : X





Mission : Ambulance


Maintenance Status.Maintenance Type : Scheduled Maintenance

Maintenance Status.Maintenance Items Involved : Work Cards

Component

Aircraft Component : Oxygen System/General



Person

Reference : 1

Location Of Person : Company

Reporter Organization : Contracted Service





Events

Anomaly.Aircraft Equipment Problem : Critical





Result.General : Flight Cancelled / Delayed


Assessments





Narrative: 1

While the aircraft was out of service for other scheduled maintenance I replaced the

gaseous O2 bottle assembly that was due for its 36 month. After going through all the leak

checks and purging procedures as outlined in the procedures for the system. I safety wired

the manual shut off valve in the closed position on the regulator, it should have been

safety wired in the open position. During the time the aircraft was back in service, the O2

system quantity showed full.

Five days later I was contacted by the pilot stating the O2 system was full but no flow to

the service ports. I was unable to quickly determine what was wrong and I was thinking

while the medical interior was going back in the aircraft one of the clear flex O2 tubing was

pinched, which would require a removal of the overhead and side walls of the cabin

interior.

We had the spare EC135 at our base so I made the call to move the crew over to that

aircraft. I spent the rest of my time that night preparing the spare aircraft. I reach the end

of my duty day after the spare aircraft was ready. I passed on the O2 problem on to the

second base mechanic. He went thru the system and determined that the manual shut off

was in the closed position. (Note in the [company's aircraft configuration] the manual shut

off is not used as with other STC's AKA pilots shut off.)

Two days later I came back to work and started to work the ongoing air conditioning MEL.

During the course of the day I started to put the aircraft back together, I read the pass

down note of where my partner left off and realized my mistake. I safety wired the manual

shut off valve to the on position, verified O2 flow and installed the cover to the bottle.

I have been here for about 2 months. During this time frame both of the mechanics have

average over 60 hours a week dealing with scheduled and unscheduled maintenance on

this aircraft with very little off time. A week before my mistake on the O2 system, I was in

the hospital for a day and a half for a heart issue and I am currently on a 30 day 24 hour

heart monitor. Not using this as an excuse but it is a contributing factor.

It was an honest mistake made by me. All leak checks and purging was checked prior to

the safety wiring of the valve. I would suggest that instead of just reading what is on the

indicator and calling it good that the medical crews do a quick flow test daily as part of

their routine. It was 5 days from the mistake with the safety wire and from the time it was

found, 2 of those days was with the aircraft back in service for medical duty.

Synopsis

During scheduled maintenance on a Helicopter ECD-EC135 a mechanic safety wired an O2

bottle manual shutoff valve in the closed position when it should have been in the open

position.

ACN: 1348316 (25 of 50)

Time / Day

Date : 201604


Place



Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : MBB-BK 117 All Series



Mission : Ambulance


Airspace.Class G : ZZZ

Component

Aircraft Component : Service/Access Door



Person

Reference : 1








Human Factors : Other / Unknown

Events






Result.Aircraft : Aircraft Damaged

Assessments




Narrative: 1

After a 2 hour four legged patient flight on approach back to [the medical center], the

inspection side of the hydraulic cowling came open and struck the blades. Two flight crew

members were on board. I can only assume my initial and subsequent pre-flight walk

arounds were deficient. Do not allow other pre-flight factors to distract one from security

of cowlings inspection.

Synopsis

The Captain of a medevac helicopter flight reported that an external inspection access

door opened in flight and struck the rotor blades. The flight landed safely and there were

no injuries reported.

ACN: 1345784 (26 of 50)

Time / Day

Date : 201604


Place



Environment


Light : Daylight

Aircraft

Reference : X






Mission : Ambulance




Component

Aircraft Component : Generator Drive



Person

Reference : 1









Events





Result.Flight Crew : Landed in Emergency Condition

Result.Flight Crew : Inflight Shutdown

Assessments



Narrative: 1

My shift started at XA30 and I showed up twenty minutes early to do my preflight and

paperwork. Upon completion of those two things, I briefed the crew on weather and went

over engine failure and single engine landings as my daily safety topic. The tones went off

shortly after XA30 for an inter-facility transfer. We accepted the flight. The flight to the

hospital was as planned with no issues. I departed the hospital with two medical crew, a

baby (patient) and patient's mother on board. Shortly after leveling off at altitude the GEN

OVHT caution appeared on the number one side of the CAD. I shut the number one

generator off and after one minute the light was still illuminated, so I announced to the

passengers that I need to do a single engine shutdown and I then did the single engine

shut down of the number one engine. I watched my torques limits closely and beeped up

my rotors. I remained within the normal One Engine Inoperative limits during the whole

procedure. Once everything was under control I ask the nurse to read me the GEN OVHT

emergency procedure to make sure I hadn't missed a step. All was good.

The crew made the call to [company] and I contacted approach control and let them know

I would need to come in and land at the airport. They cleared me to land on Runway XX

and I requested the taxiway instead. They approved me as requested. I transferred to the

tower frequency and continued inbound to the airport. Along the way I briefed the crew

but they were already aware of the procedure because this exact emergency procedure

was discussed in our safety topic of the day briefing. I communicated with the mother to

make sure she understood what the landing was going to be like. At 200 feet I let the

passengers know that we needed to have a sterile cockpit. I maintained 40 knots until I

was within 12 feet and started to slow up. I knew I wouldn't have enough power to hover

because my hover power at the hospital was over 70% torque. When I reached an

airspeed in which I could no longer bring in power I gently lowered collective and we

completed the flight with a running landing. I went into the OEI (One Engine Inoperative)

transient just before touchdown for a couple seconds. Everyone was ok and the patient

was transported by our other base. After landing, I walked around the helicopter to inspect

for any signs of fire and didn't find anything.

Synopsis

MBB BK-117 pilot reported they had a GEN OVHT caution light which required a shutdown

of the number one engine. Successful landing was made at an airport.

ACN: 1343602 (27 of 50)

Time / Day

Date : 201603


Place




Environment


Light : Daylight

Aircraft : 1

Reference : X


Aircraft Operator : Government

Make Model Name : Agusta Undifferentiated or Other Model



Mission : Ambulance




Aircraft : 2

Reference : Y


Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer



Person

Reference : 1


















Events









Assessments



Narrative: 1

Near miss occurred when departing from the hangar at a tower controlled airport.

Sequence of events leading up to the near miss are as follows: aircraft requested taxi and

departure to the NE. Tower acknowledged and cleared the aircraft to taxi as requested.

Aircraft taxied out, completed takeoff checks and departed. After takeoff ATC Tower made

immediate evasive maneuver calls to prevent a collision with other traffic that had recently

departed.

This close call was a clear case of a pilot requesting a clearance and hearing the clearance

that he was expecting, not the clearance that was actually given. Tower gave a taxi

clearance and a taxi clearance only. At no time did the tower say "cleared for takeoff". The

pilot was expecting the Tower to issue a taxi and takeoff clearance in one transmission,

but only a taxi clearance was given. [Aircraft] took off without ever hearing or receiving a

"cleared for takeoff" in their clearance.

Synopsis

AW-139 helicopter pilot reported an NMAC when they took off without clearance.

ACN: 1343584 (28 of 50)

Time / Day

Date : 201603


Place




Environment

Light : Daylight

Aircraft : 1

Reference : X




Make Model Name : Jet/Long Ranger/206



Flight Plan : VFR

Mission : Ambulance




Aircraft : 2

Reference : Y




Person

Reference : 1













Events







Assessments



Narrative: 1

On final to [hospital] a helicopter flew right in front of us flying NW. I do not believe they

were on the radio. We were talking to ZZZ Approach, Medcom on FM, and our ZZZ

Operations (air-evac). We were less than 1 mile from landing. We had been handed off

from approach to advisory but remained on ZZZ approach to monitor traffic. We think they

lifted from within the surface area but are not sure of that because we didn't see them till

they were right in front of us between us and our landing area. We deviated left and down

to avoid and after landing on the helipad called ZZZ approach/tower on the phone to

discuss.

Synopsis

BH206 pilot reported an NMAC on final to a hospital helicopter pad.

ACN: 1341241 (29 of 50)

Time / Day

Date : 201603


Place

Locale Reference.Airport : SMO.Airport



Environment

Weather Elements / Visibility : Haze / Smoke


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : SMO


Make Model Name : Skylane 182/RG Turbo Skylane/RG



Flight Plan : IFR

Mission : Personal

Nav In Use.VOR / VORTAC : SMO


Airspace.Class D : SMO

Person

Reference : 1



Reporter Organization : Personal


Qualification.Flight Crew : Flight Engineer










Events

Anomaly.Deviation - Altitude : Overshoot

Anomaly.Deviation - Altitude : Crossing Restriction Not Met






Assessments





Narrative: 1

On final vector into SMO I was given a quick vector to intercept final, descend from 6000

feet to 4000 feet and cleared for the approach. As a result, I crossed BEVEY about 800

feet high and fast. As I descended I went to full flaps and noticed my vacuum compass

was 20 to 30 degrees off (probably due to the low power setting). More time was wasted

confirming my lateral position. Upon contacting tower I was cleared for the straight in

approach and cleared to land. Runway was in sight. A short time later tower gave me a

low altitude alert and indicated that I was supposed to cross CULVE at 1120 feet. It is

impossible to cross CULVE at 1120 feet (circling MDA) and land straight in.

I was lower than I wanted to be when I got the alert from tower. Distraction due to high

rate of descent and compass error did not help. ATC has to find a better way to bring in

traffic without the ram dump approach. It would also help if an LPV approach was

available.

Synopsis

C182 pilot reported being admonished by the SMO Tower Controller for crossing CULVE

below 1120 feet during the VOR Approach to SMO in VMC. The VOR Approach is a circle to

land only approach with an MDA of 680 feet.

ACN: 1339538 (30 of 50)

Time / Day

Date : 201603


Place




Environment



Light : Night


Aircraft

Reference : X





Flight Plan : None

Mission : Ambulance

Flight Phase : Takeoff



Component

Aircraft Component : GPS & Other Satellite Navigation



Person

Reference : 1













Events





Result.Aircraft : Equipment Problem Dissipated

Assessments




Narrative: 1

Loss of reception on both GPS units when departing the helipad. Ground units use this pad

as an LZ due to very few options available in that area. Loss of reception occurred at

XA:40 and GARMIN 530 unit gave me the error message and reacquired satellites in about

10 sec and the GARMIN 430 unit took about 3-4 minutes to reacquire satellites. Reception

was regained and no other anomalies.

Synopsis

Helicopter pilot reported a loss of GPS signal on both Garmin units during departure from a

hospital. The outage lasted 10 seconds on the G530 and three to four minutes on the

G430.

ACN: 1330540 (31 of 50)

Time / Day

Date : 201602


Place



Environment



Ceiling : CLR

Aircraft

Reference : X



Make Model Name : Citation V/Ultra/Encore (C560)



Flight Plan : IFR

Mission : Ambulance


Component

Aircraft Component : Aileron Trim System



Person : 1

Reference : 1









Analyst Callback : Completed

Person : 2

Reference : 2









Events





Result.Flight Crew : Overcame Equipment Problem

Result.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Landed in Emergency Condition

Assessments




Narrative: 1

WX was good so PIC accepted flight, first flight of day checks were completed, med crew

was loaded, engines started. All before taxi checks were completed and we got a taxi

clearance, all taxi and before takeoff checklist was completed. Takeoff roll was normal,

and through V1 and Vr everything felt normal, however what I initially noticed was that it

was increasingly hard to hold runway heading which was what I was assigned. The yoke

control pressure to keep wings level was becoming so hard that it took both hands to

accomplish the task, I then checked the trim indicators to see if they were out of whack

but the indicators were showing centered or very close.

I asked the PNF who was also the PIC to feel the controls, we had a positive exchange of

controls then he agreed that there was a control issue at which point he visually checked

both the aileron and rudder trim indicators that appeared normal. Once he had control I

tried to turn the trim knob and it felt bound but didn't want to overpower it because I was

not the PF and could not experience any inputs that I made. We requested to turn back

and ATC asked what the issue was and we told them we were having control problems. We

turned back to the field and switched controllers. I checked engine gauges to make sure

everything else was normal and it was, the PIC was struggling to keep wings level and we

discussed if it was harder to hold the faster we went and he said he thought it was, which

made me again check the trim indicators but again they looked normal. We were given a

visual approach which we accepted, then discussed how we wanted to bring down flaps

and gear being cautious not to exacerbate the situation. While on final the PIC again tried

adjusting the trim and got movement and the rolling right tendency went away and a

normal landing was conducted.

Callback: 1

The reporter believes that several issues were involved in this incident. First, maintenance

worked on the aircraft the day prior and this was the first flight after. Second, the reporter

does not fly the CE560 very often and was not familiar with the force required to adjust

the aileron trim on this aircraft. And last the aileron trim indicator was mis-indexed so the

gauge did not reflect that the ailerons were out of trim. Maintenance was able to quickly

re-index the aileron trim gauge.

Narrative: 2


Synopsis

CE560 flight crew experienced a strong rolling tendency and aileron trim binding during

initial climb then the controls are passed to the PIC in the right seat. The crew elects to

return to the departure airport and the PIC is able to adjust the aileron trim to neutralize

the rolling tendency prior to landing.

ACN: 1329046 (32 of 50)

Time / Day

Date : 201602


Place

Locale Reference.ATC Facility : HWD.Tower



Environment


Light : Night

Aircraft : 1

Reference : X

ATC / Advisory.Tower : HWD

Aircraft Operator : FBO

Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear




Route In Use : None

Airspace.Class D : HWD

Aircraft : 2

Reference : Y

ATC / Advisory.TRACON : NCT





Mission : Ambulance


Airspace.Class D : HWD

Person

Reference : 1

Location Of Person.Facility : HWD.Tower












Events








Assessments




Narrative: 1

Aircraft Y flying northbound on a NCT sector tag penetrated Delta airspace without

coordination. Converging traffic advisories issued to Aircraft X on HWD frequency on final

about Aircraft Y converging. Called NCT to tell them to turn Aircraft Y to the east to clear

Delta airspace. The controller stated that he had traffic in sight but never initiated a point

out to transition through Delta airspace nor bothered to call HWD to advise that his

Aircraft Y had Aircraft X in sight.

Familiarize NCT controllers about point outs prior to entering Delta airspace or remain

completely clear of it.

Synopsis

HWD Tower Controller reported of Class Delta airspace violation. The Controller working

the Approach Control position was called by HWD Tower Controller and asked about the

violating aircraft. Converging traffic was being worked by the Tower Controller. Overlying

TRACON Controller never asked for a point out or advised that visual separation was being

used.

ACN: 1327145 (33 of 50)

Time / Day

Date : 201601


Place

Locale Reference.ATC Facility : FXE.Tower

State Reference : FL


Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : FXE





Flight Plan : IFR

Mission : Ambulance



Airspace.Class D : FXE

Aircraft : 2

Reference : Y

ATC / Advisory.Tower : FXE


Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear



Mission : Personal


Person

Reference : 1

Location Of Person.Facility : FXE.Tower







Events


Anomaly.Conflict : Ground Conflict, Less Severe

Anomaly.Ground Event / Encounter : Person / Animal / Bird



Result.Flight Crew : Executed Go Around / Missed Approach



Assessments


Primary Problem : Environment - Non Weather Related

Narrative: 1

This is a series of events involving the coyote problem on the field. Coyote observed on

runway, Med evac on approach was issued a go around by Local Control. Security was

summoned to chase the coyote off the field. A pilot on the ramp reported a coyote,

security vehicle was summoned to chase the animal off the field. FAA Vehicle eastbound

on taxiway reported a coyote just north of the approach end of the runway. The vehicle

chased the animal into the treeline. Aircraft Y landed and reported almost hitting a coyote

on landing roll, the animal cut right in front of him on the runway. A coyote was spotted

near a taxiway near the runway. Security was summoned to chase the animal off the field.

A coyote was spotted west of a runway, security was summoned to chase the animal off

the field.

This has been going on since last summer or fall. The population of coyotes is growing as

we often see them in pairs or small groups now. Airport operations does not seem to be

able to achieve the appropriate permissions to handle the situation, e.g. trap or shot, from

the state or local government. This problem is getting progressively worse and aircraft

safety is at risk daily. The above list is a typical day of dealing with the coyote problem on

the airport here.

Get the presiding authority, whomever that may be, to issue the order to handle this

escalating safety problem and capture or kill these animals before there is an accident.

Synopsis

FXE Tower Controller reported a recurring problem with coyotes. An aircraft was issued a

go-around due to a coyote on the runway. A landing aircraft reported almost hitting a

coyote on the runway.

ACN: 1322533 (34 of 50)

Time / Day

Date : 201501


Place


Environment




Light : Night

Aircraft

Reference : X



Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil



Mission : Ambulance


Person

Reference : 1











Events


Anomaly.Ground Event / Encounter : Other / Unknown


When Detected : Aircraft In Service At Gate


Result.Flight Crew : Regained Aircraft Control


Assessments

Contributing Factors / Situations : Company Policy



Narrative: 1

The helicopter was parked on a dolly that was chalked on both sides with heavy rubber

chalks and connected to the truck used for towing. Keeping the truck attached to the dolly

for takeoff and landing is a standard operating procedure by all pilots. I was parked in the

usual start up location, which is between two rows of hangars, with a fence and cars

behind me and various small aircraft in between both rows of hangars. The area is a

confined, albeit roomy area in my opinion. The ramp surface at the time of startup was ice

with pockets of standing water. After starting the helicopter, when slowly advancing the

Fuel Flow Control Lever (FFCL) to fly, the dolly, with the helicopter on it, started to rotate

to my right (to be clear the nose of helicopter went right, tail of helicopter went left). I

immediately aborted the start. The dolly continued to rotate about 60 degrees from its

starting point with the tail moving toward our hangar. The tail cleared the hangar by about

25 feet; I was parked squarely in the middle of the allotted area. If I hadn't been attached

to the truck, I believe the helicopter would have slid into our hangar. There was no

damage to anything. After submitting a safety report in hopes of fixing the safety issues

associated with this event, I was informed via email the following:

"The Towing Equipment Policy states the following: dollies - tow vehicles shall be moved a

safe distance away from dollies during aircraft takeoff and landing. The requirement to

maintain 15 feet clearance from obstacles on the ground for takeoff and landing applies as

well."

I have never seen the towing equipment policy referenced above. I have read our

operations manual more than once and was given adequate operations manual training in

my initial new hire class and was aware of the 15 foot rotor disc clearance policy for

takeoff and landing. However, I did not realize the 15 feet included the tow truck. I was

trained to leave the truck attached to the dolly for reference as this is our standard

operating procedure at both bases and by all pilots.

Please note: I believe having the truck to use as a visual reference and a solid anchor is

imperative for our safety of operations. The truck provides a great visual reference

especially in blowing snow and white out conditions which we encounter often.

I have operated numerous times, in similar conditions, off the dolly while attached to the

truck and chocked and did not realize it would rotate as it did. This should be included in

winter operations training for the pilots so they are not caught by surprise, like I was.

If the tow truck is not to be attached to the dolly for takeoff and landing (which again

compromises our safety of operations), I believe the towing equipment policy should be

incorporated into our operations manual and training should be revised to reflect this

policy.

Synopsis

An AS-350 pilot described a helicopter dolly rotating on an icy ramp during engine start

while preparing to fly off the dolly.

ACN: 1320955 (35 of 50)

Time / Day

Date : 201512


Place

Locale Reference.ATC Facility : ZJX.ARTCC

State Reference : FL


Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Center : ZJX





Flight Plan : IFR

Mission : Ambulance



Airspace.Class A : ZJX

Aircraft : 2

Reference : Y

ATC / Advisory.Center : ZJX


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZJX

Person

Reference : 1

Location Of Person.Facility : ZJX.ARTCC











Events








Assessments





Narrative: 1

Sector 17 began handing off Aircraft Y at 27000 feet. I noticed an enhanced limited data

block within sector 28 Low beneath sector 17, Aircraft X. I brought up the full data block

and noticed it may hinder the ability of the arriving flight to descend, so I requested sector

17 to shortcut Aircraft Y to ZZZZZ intersection before accepting the handoff to allow sector

17 to safely climb Aircraft X. I descended Aircraft Y to 24000 feet as I am allowed to do by

SOP. Aircraft X was handed off to sector 17 climbing to 23000 feet. Sector 17 gave a climb

to this Aircraft X to an altitude above my airspace. Aircraft X came within 2.5 miles of my

airspace at 26000 feet and was finally through my airspace approximately 10 miles in. No

one called me with a point out for Aircraft X climbing through my airspace.

It's me once again with yet another airspace violation from the Central Area at ZJX. I just

sent one in on that area from [three days prior] and elaborated on how this Area has

become inherently unsafe. I am going to fill out an ATSAP for every single one that affects

the sector that I am working from this point forward. I understand us controllers are

human and make mistakes. We all get in a bind from time to time and need an "out" from

fellow controllers. I have no issue on that. The issue is with many controllers completely

disobeying our basic ways to move traffic safely and efficiently through the NAS. The basic

ways are Point outs, APREQ's, etc. I'm actually very unhappy with how this has progressed

in the time I have been hired by the FAA and at ZJX. I look forward to hearing from you

and what steps are going to be taken for people to be accountable for not doing their job

correctly and safely.

Synopsis

An aircraft was climbed through a Controller's sector without a handoff or point out.

ACN: 1318864 (36 of 50)

Time / Day

Date : 201512


Place

Locale Reference.Airport : CRP.Airport

State Reference : TX


Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : CRP

Aircraft Operator : Corporate




Flight Plan : IFR

Mission : Ambulance



Airspace.Class C : CRP

Aircraft : 2

ATC / Advisory.TRACON : CRP



Flight Plan : IFR


Airspace.Class C : CRP

Person

Reference : 1

Location Of Person.Facility : CRP.TRACON








Events









Assessments




Narrative: 1

Aircraft Y requested an opposite direction practice approach which was approved by the

Tower. Tower scanned down 2 strips, one of which was Aircraft X. TRACON called back to

ask if we needed to break Aircraft Y off of the approach, local control responded with no.

I'm not sure how much time passed, Aircraft Y was well inside of the cutoff point per our

local opposite direction operation procedures when Aircraft X departed on a 240 heading

climbing to 3,000 feet. A supervisor was working Local Control. Our supervisors get the

minimum amount of time needed to retain currency. Supervisors are not proficient in the

tower. I do not have a solution to this problem, but something obviously needs to happen.

Synopsis

CRP TRACON Controller reported an opposite direction landing and takeoff occurred at CRP

airport with less than the required miles of separation according to the local directives.

ACN: 1318643 (37 of 50)

Time / Day

Date : 201308


Place




Environment

Weather Elements / Visibility : Thunderstorm

Light : Daylight

Aircraft

Reference : X



Make Model Name : PC-12



Flight Plan : IFR

Mission : Ambulance





Person

Reference : 1












Events








Assessments


Contributing Factors / Situations : Company Policy

Contributing Factors / Situations : Equipment / Tooling


Contributing Factors / Situations : MEL

Primary Problem : Equipment / Tooling

Narrative: 1

Experienced a failure of the number 1 nav/radio, a Garmin 650. Radio was mis-wired by

installation facility and company maintenance accepted aircraft without knowing mis-

installation. Navigation portion of two-in-one radio was working correctly. A big red cross

appeared on and off in the communications section of radio. Checked MEL list in the

aircraft's GOM. MEL gave instructions on procedure for separate nav/com radios and not

for current unit. Was not sure what to write. I had a patient on board and decided to

continue with the flight using the number two radio. EPS in aircraft is installed and is

supposed to provide power to stand-by attitude indicator, transponder, clock, nav and com

radios. On initial power up, those items powered up as normal. After normal engine start,

com radio section showed previously mentioned red cross. Nav portion showed to be

working normal. Red cross disappeared and came back several times. While red cross was

on screen, I was unable to make any radio transmissions.

As I taxied to the runway, the red cross would appear on and off. I used the second radio

to make all transmissions. Departed under VFR and remained under VFR conditions until I

contacted ARTCC. I was given an IFR clearance to my destination. At that point, I noticed

that transponder was not working. I then also noted that clock and stand-by attitude

indicator were not working. As I mentioned before, on original power up of EPS, those

items worked fine. I was distracted by red cross and never noticed that other items

powered by EPS were not working until I was given a transponder code. I could not figure

out why other items were not working. I thought EPS could not be the reason since the

nav portion of the Garmin 650 was still working. I landed and had maintenance look at the

issue. Maintenance found EPS switch to be intermittent, thus the on/off red cross

appearing on com section. However, after further investigation, the Garmin 650 was found

to be not installed correctly. Apparently, even though both nav and com radios are in one

unit, they have separate power sources which should have been connected to the EPS

switch. In this case, the communication section was wired to the intermittent EPS switch

while the navigation section was connected to another source. I should have contacted

maintenance instead of continuing flight with the problem. The Garmin 650 was a new

radio unit to us and I was not familiar with the meaning of the red cross. I had had a

previous flight in the same aircraft where the red cross had come and off twice in quick

succession without any perceivable adverse effects. Communication with TRACON at the

time were not in jeopardy. This was mentioned to maintenance and they had no answer to

issue either. It was basically a wait and see if it happens again.

Synopsis

An aircraft departed with a known radio/navigation component malfunctioning. In flight

the pilot noticed the aircraft's transponder, clock, and standby attitude indicator had failed.

ACN: 1317220 (38 of 50)

Time / Day

Date : 201512


Place

Locale Reference.ATC Facility : PHL.Tower

State Reference : PA


Environment

Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.Tower : PHL





Flight Plan : VFR

Mission : Ambulance


Airspace.Class B : PHL

Aircraft : 2

ATC / Advisory.Tower : PHL

Make Model Name : Small Transport, Low Wing, 2 Recip Eng


Flight Plan : IFR




Aircraft : 3

Reference : Z

ATC / Advisory.TRACON : PHL


Make Model Name : Military Transport



Flight Plan : VFR

Mission : Skydiving



Person

Reference : 1

Location Of Person.Facility : PHL.Tower












Events






Assessments




Narrative: 1

Aircraft Z, was orbiting [nearby] for a practice parachute jump. There was not a TFR in

effect for this operation. The schedule I had showed that the jump would happen from

5,500. Aircraft Y, was on final to 27R. Aircraft X had called me 10 south of the airport for

Class Bravo transition, north of the 27R final approach course and the [area of orbit].

When Aircraft X was about 3 miles south of Aircraft Y, I issued traffic.

Aircraft X replied that he was looking. I asked Aircraft X if he could turn 15 degrees right,

as this would point him at Aircraft Y's tail. He replied that he could. I issued the

instruction, and then updated the traffic call to Aircraft X. Aircraft X reported the traffic in

sight and that he could maintain visual separation. I told Aircraft X to maintain visual

separation from and pass behind Aircraft Y. All of these calls where within about one

minute. The 15 degree turn/passing behind Aircraft Y, put Aircraft X as close to going over

top of the [orbit area] as he could have been without trying. During this time, I noticed

that Aircraft Z was still at 4,500.

As Aircraft X was passing the [orbit area], another controller said that he could see the

jumpers coming down. Aircraft Z was still at 4,500, and I was given no notice that

jumpers where away, or that they would be jumping from any altitude other than 5,500.

The only plan effected to separate traffic from the jump zone, was to have all PHL arrivals

land 27R, and to have Aircraft Z remain north of I-95 (which runs between the [orbit area]

and the 27R final). Aircraft Z notified the approach controller one pass prior to jumpers

way. The approach controller did not notify the tower. While I was expecting to receive

notification, the approach controller thought that the TRACON supervisor would notify the

tower supervisor. This did not happen. There were not any pre-planned notification

procedures.

Synopsis

PHL Local Controller reported a loss of separation when a helicopter passed under an

aircraft transporting skydivers. The Controller had not been advised that the jumpers had

exited the aircraft. Reporter noted a lack of communication between TRACON and Tower

supervisors.

ACN: 1315961 (39 of 50)

Time / Day

Date : 201512


Place

Locale Reference.ATC Facility : HSV.TRACON

State Reference : AL


Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.TRACON : HSV


Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Ambulance



Airspace.Class C : HSV

Person : 1

Reference : 1












Person : 2

Reference : 2













Events









Result.Flight Crew : Returned To Clearance

Assessments




Narrative: 1

We were vectored by approach to the East for runway 18L. We were vectored well North of

the airport, and then to the west. We were then given traffic, and then cleared for a visual

approach. At some point, we lost sight of HSV, and acquired HUA by mistake. As we

proceeded inbound to the runway, we had traffic called to us, and then were given a go-

around. It was at this point that we realized we had the wrong airport identified. We were

given straight ahead to 4,000 feet, and then heading 090.

The first officer and I are filling this out together, and after discussion we believe the

biggest contributing factor in this situation is that we fly international missions frequently.

So in this case, we failed to put proper emphasis on this flight as we naturally do in all of

our flights. This is, of course, not an excuse, just that we could have put more emphasis

on this flight so as not to become complacent. Further contributing factors were several.

First, the lights on runway 18L at HSV were not very brightly lit. The lights of runway 17 at

Redstone, HUA, were lit to full intensity. So as we were vectored to the west and given the

traffic the brighter runway visually prevailed. Also there was a shift change with the

approach controller we were talking to. This happened when we were on the downwind

leg. We believe this extended our downwind leg further, and thus caused two things: first,

for us, that as close as the two airports are together, by the time we were turned back to

where we could see the runway, visually, the two airports seemed way closer together.

Secondly, at some point, the new controller asked which airport we were going to, so we

believe there was confusion there, as well, which allowed the approach to continue maybe

a bit further than would have otherwise.

After much discussion, we believe in moving forward, what we will do to prevent further

occurrence, is, #1...that we will not consider any flight of lesser importance. We will

consider every takeoff and landing to be of utmost importance. Complacency is not an

option. #2...We intend to, whenever going in to a runway served by an approach, to shoot

that approach even if in VFR.

Narrative: 2


Synopsis

Flight crew reported lining up for HUA airport instead of their destination, HSV, during a

night visual approach.

ACN: 1309600 (40 of 50)

Time / Day

Date : 201511


Place

Locale Reference.Airport : CPS.Airport

State Reference : IL



Environment


Light : Night

Aircraft : 1

Reference : X

ATC / Advisory.Tower : CPS





Flight Plan : None

Mission : Ambulance


Route In Use : None

Airspace.Class E : T75

Aircraft : 2

Reference : Y


Make Model Name : UAV - Unpiloted Aerial Vehicle


Flight Plan : None


Route In Use : None

Airspace.Class E : T75

Person

Reference : 1

Location Of Person.Facility : CPS.Tower








Events






Result.General : Police / Security Involved




Assessments





Narrative: 1

A helicopter was flying VFR southbound not in communication with air traffic control. The

pilot checked with CPS tower and reported a near miss UAS incident. The aircraft was at

1,400 ft and 7 NW of CPS. The pilot reported that the drone was less than 100 ft from the

helicopter and had to take evasive action with a 60 degree banking turn to avoid the

drone. There was no reported damage to the aircraft and crew was not injured. The color

of the UAS was reported as black and grey, 3x3 ft, 4 propellers with balloons on top. Law

enforcement was contacted and police dispatched. UAS checklist was followed and

completed. Acn and no further incident occurred.

Add law enforcement procedures to checklist. I was also not sure of what was to be

expected of me with law enforcement. I used my best judgment and had the police

dispatch cars to the possible scene from where the UAS was launched.

Synopsis

A helicopter pilot called ATC after a NMAC with an UAS at 1,400 feet over the STL

metropolitan area.

ACN: 1309270 (41 of 50)

Time / Day

Date : 201511


Place

Locale Reference.Airport : CLE.Airport

State Reference : OH

Relative Position.Angle.Radial : 60



Environment

Flight Conditions : IMC



Light : Night


Aircraft

Reference : X

ATC / Advisory.Tower : CLE


Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Ambulance



Airspace.Class B : CLE

Component : 1

Aircraft Component : ILS/VOR



Component : 2

Aircraft Component : Autoflight System


Person : 1

Reference : 1














Person : 2

Reference : 2











Events


Anomaly.Deviation - Altitude : Overshoot







Assessments


Primary Problem : ATC Equipment / Nav Facility / Buildings

Narrative: 1

While on an instrument approach to runway 06L at CLE, we experienced a loss of LOC and

GS prior to the final approach fix (Sasco int) and Hados intersection. We were established

on the LOC and GS was intercepting, descending out of 3000 feet when the aircraft began

to pitch up and down with the autopilot engaged. We noticed the LOC frequency on Nav 1

had change to a VOR frequency (108.??), the LOC and GS pointers were going left to right

full scale on the LOC and up and down full scale on the GS. The autopilot began chasing

the GS causing the airplane to change pitch up and down, gradually increasing in intensity.

I told the First officer we were going missed as I disengaged the auto pilot to hand fly the

airplane and execute the missed approach. Before I disengaged the autopilot, the airplane

had pitched up and I disengaged the autopilot applied forward pressure to level off. The

First Officer called ATC and reported we were executing the missed approach. We were

instructed to climb to 3000 feet on an assigned heading. At the time we were

approximately at 3400 feet and with the trim that the autopilot had applied, we were

climbing at a pretty good rate. By the time I got the trim out and the airplane descending

to 3000 feet, we were at 4200 feet. ATC came back and instructed us to maintain 4000

feet. We maintain the heading of the alternate missed approach instructions but not our

altitude do to the pitch attitude of the airplane and the back pressure applied by the

autopilot. Once I had a feel of the airplane we maintained 4000 feet and proceeded to get

vectored around for the ILS to 06R this time instead of 06L. We informed ATC of the loss

of navigation (LOC and GS) on the ILS for 06L as the reason for the missed approach.

After landing on Runway 06R, tower controller apologized about the issue with the ILS and

mentioned they received an alert regarding the ILS at the same time we called the missed

approached. The ILS for 06L was then NOTAM inop.

It appears there was an issue with the ILS signal that cause the Collins Pro Line to lose the

LOC frequency and revert or default to the VOR frequency. We had not yet extended the

gear or full flaps at the time of losing the GS. I preformed the missed and failed to notice

the FO had not retracted the flaps from Approach to the Up position, while descending

back down to the originally assigned 3000 feet altitude, we received instructions to

maintain 4000 feet. I believe this contributed to us climbing at a higher rate than I

expected making it more difficult to maintain and descended to the originally assigned

3000 feet. It was during the After Takeoff/Go Around checklist that the flaps were noticed

at the Approach position.

I feel I could have abandoned the approach a few seconds sooner and this may have

prevented the airplane from chasing the glide slope to the point of pitching up and down

as much as it did and adding so much nose up elevator pressure and trim. I should have

checked the flap position sooner and that may have helped me maintain altitude sooner

and with less deviation. [The next day] I checked the NOTAMS for CLE and it showed the

ILS 06L inop.

Narrative: 2

On the ILS to 6L at CLE the localizer started drifting and the GS went from on slope to full

scale above then full deflection down. We were at 1900 AGL. We initiated a missed. When

we notified tower we were at 3000ft. We were told to level. We went through the altitude

and were told to level at 4000. Tower vectored us for 6R. We notified tower about ILS

malfunction. They took our report and mentioned they had an "alarm." We completed the

ILS 6R with no incident.

Synopsis

An air taxi flight crew reported an issue with the ILS Runway 6L signal at CLE that caused

an unexpected pitch up and down with the autopilot engaged.

ACN: 1307864 (42 of 50)

Time / Day

Date : 201511


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Ambulance



Airspace.Class A : ZZZ

Person

Reference : 1

Location Of Person.Facility : ZAN.ARTCC











Events


Anomaly.Deviation - Altitude : Excursion From Assigned Altitude







Result.Flight Crew : Returned To Departure Airport





Assessments





Narrative: 1

Aircraft X was at 36000 feet. Frequencies were somewhat congested and a Radar Assist

with trainer had just plugged in to assist. Aircraft X experienced what I can only assume

was rapid decompression. The first time Aircraft X called, the radio was very scratchy and

unreadable, but upon reviewing the tapes he advised of either needing an emergency

descent, or that he was performing one. I did not hear this transmission due to other

aircraft on frequency and the fact that it was very difficult to read. Aircraft X called at least

twice more advising of their intentions, but I still could not discern what aircraft was

calling me due to the poor quality of the transmission.

Perplexed, my best guess was that the aircraft calling was requesting a popup IFR

clearance in the area. I asked the aircraft to repeat their call sign and intentions again. At

this point, the call sign was a bit more clear and my Radar Assist pointed out the fact that

it was indeed Aircraft X who had turned 180 degrees back and descended ~20,000 feet

without a clearance to do either. Since Aircraft X, [which] I had been working, had safely

climbed through any traffic conflictions and was on course, I failed to correlate that fact

that the call sign being used by the nearly unreadable pilot was the same call sign as the

aircraft I thought to be at cruise altitude. Still convinced that the aircraft calling was

requesting an IFR popup, I radar identified them unnecessarily and asked if they were

"VFR" since they were under 18000 feet. The pilot indicated that they were in VFR

conditions and requested to return to their departure airport. I instructed the pilot to

maintain VFR and issued an altimeter setting. It was only at this time that I started to

realize exactly what had occurred. I immediately inquired with the pilot if they were

experiencing an emergency or required assistance. Their response was that they had

performed an emergency descent, but no longer needed assistance or were an emergency.

My Radar Assist coordinated verbally with TRACON that the aircraft was VFR and returning

with no assistance required and effected a manual handoff. I issued a communication

change to TRACON. One minute later, Aircraft X checked back on asking for "an altitude",

presumably to pick up another IFR clearance as the weather required it. I issued another

communication change to TRACON.

The rapid sequence of unusual events left me very confused even after the dust had

settled. My initial impression was that Aircraft X had just acquired on the radar because

they had a flight plan on file and had squawked the code associated with it and auto

acquired. I also considered the possibility that the aircraft calling me should have been on

a different center frequency so I quickly looked at surrounding sectors searching for a call

sign to no avail. In reality, Aircraft X had departed IFR, I took the handoff and climbed him

to his requested altitude. As soon as Aircraft X was clear of any conflictions, I "forgot"

about the aircraft.

There was no need to expend mental energy on the aircraft anymore in my estimation,

and the next time I would address the aircraft would be when it approached the adjacent

sector boundary and needed to be handed off. I've found this to be a very effective

working practice as it allows for attention to be focused on more important tasks. In this

instance, those items included a large military recovery from multiple MOAs, sequencing,

and airport area traffic. I'd like to make it very clear that I'm not making excuses nor am I

blaming this incident on high workload or combined sectors. I only mention this to help

understand how a controller could possibly not recognize the call sign of an aircraft for

which he is responsible for. There was another west bound IFR aircraft behind Aircraft X at

15,000 feet when they began their turn, but thankfully were far enough behind not to be a

factor by the time Aircraft X descended through their altitude (10-15 miles of separation

existed).

Synopsis

ARTCC Controller reported an aircraft calling with an unreadable request, but the

Controlled believed the aircraft was in distress. Aircraft was at 3600 feet descending and

reversing course. Controller improperly issued aircraft a VFR clearance and sends them to

TRACON even though the aircraft was IFR and wishing to remain as such.

ACN: 1307731 (43 of 50)

Time / Day

Date : 201511


Place




Environment


Light : Daylight

Aircraft

Reference : X




Mission : Ambulance


Component : 1

Aircraft Component : Aircraft Logbook(s)

Manufacturer : Eurocopter


Component : 2

Aircraft Component : Powerplant Mounting

Manufacturer : Turbomeca Arriel


Person

Reference : 1

Location Of Person : Hangar / Base








Communication Breakdown.Party1 : Maintenance

Communication Breakdown.Party2 : Other

Communication Breakdown.Party2 : Maintenance

Events





Were Passengers Involved In Event : N

When Detected : Routine Inspection


Assessments




Contributing Factors / Situations : Manuals



Narrative: 1

While at the maintenance hangar, where a BK-117C1 [Eurocopter] was undergoing routine

scheduled maintenance work, it was brought to my attention by our Lead Mechanic that

there was an Engineering Order issued by Company Engineering May 2015 for the aircraft,

regarding a Mandatory Service Bulletin (MSB) from the Engine Manufacture (Turbomeca)

issued March 2015 requiring a Daily Visual Check of the Engine Front Support pins after

the last flight of the day and subsequently [the need to] make a Logbook entry regarding

the completion and result of the inspection. Also required, was a more Detailed

Maintenance Check of the mount that should be completed every 15 hours with an

accompanying compliance Logbook entry.

A Visual Check of that pin was performed as a part of the normal Daily Aircraft Preflight

Inspection. The information regarding the change to require the Logbook entry specified

by Company E/O (Engineering Order) for the MSB (Mandatory Service Bulletin) was never

disseminated, addressed, nor included in the Pilot Maintenance Servicing Training (PMST).

There was no information provided via the Company Form or the [outside] Contracted

Maintenance Compliance Tracking Systems about this Inspection Logbook entry

requirement; nor was it listed on the Pilot Maintenance Servicing Procedures (PMSP)

Training Checklist and Signoff Forms. After further discussions and searching, it was

discovered that the procedure narrative had been added to the PMSP program, but not

followed through and included in the Checklist/Signoff Form. After becoming aware of this,

I inquired further with our Maintenance and Aircraft Compliance Staff regarding this and

any specific training that may be required for us to do the inspection and Logbook entry.

Our BK [Aircraft] Compliance Staff was aware of this procedure for the BK-117C2 (or EC-

145) with these engines, but since the company had only a couple of the C1 versions of

the Model affected, the information didn't get to the Operators by the usual system

process, resulting in that none of the Line or Compliance pilots operating this Aircraft were

aware of the requirements of the Company's E/O, and so none of the required Logbooks

showing the completion of the checks were made for the period of the effective date until

discovered.

The result, is that due to not being advised and my not being aware of the requirement of

Company E/O, I did not comply with logging entries for the checks on the dates that a last

flight of the day inspection Logbook entry would have been required. After the mistake

was identified by our Lead Mechanic and myself, we moved to resolve the issue before

further in service [of affected aircraft] and advised the Regional Maintenance Management

and Compliance Staff and the steps [that] were taken to correct the issue.

Improve the proofing and communications process for the initiating of new procedures and

their integration into the company procedures and implementation into company policy

and practice.

Synopsis

An employee reports he was informed by their Lead Mechanic that a Mandatory Service

Bulletin inspection of Engine Front Support Pins issued by the engine manufacturer for

their BK-117C1 Eurocopters also included a logbook entry requirement after the last flight

of the day. The logbook entry requirement had not been included in the pilot maintenance

checklist/signoff form from their company.

ACN: 1305430 (44 of 50)

Time / Day

Date : 201510


Place

Locale Reference.ATC Facility : ZZZ.Tower



Environment

Light : Night

Aircraft

Reference : X

ATC / Advisory.Ground : ZZZ


Make Model Name : Super King Air 200


Mission : Ambulance

Flight Phase : Taxi

Person

Reference : 1

Location Of Person.Facility : ZZZ.Tower


Function.Air Traffic Control : Ground








Events




When Detected : Taxi


Assessments



Contributing Factors / Situations : Staffing

Primary Problem : Staffing

Narrative: 1

I was working Local and Ground combined to accommodate one hour breaks (standard

practice at this facility). A departing Dash 8 reported FOD on the runway; pilot thought it

was at the approach end. I immediately called the TRACON and informed them to consider

Runway XXR closed due to FOD. I started to taxi aircraft to Runway YY for departure. ZZZ

was in and out on Runways XXL and YY (intersecting RWYs).

With multiple arrivals (military turboprops and Air Taxi's) to Runways XXL and YY

(Lifeguard BE20 and business jets), I worked an intersecting runway operation with Local

and Ground combined. The Lifeguard flight missed his taxi instructions and sat on Taxiway

B waiting to receive his route. A C172 was confused on his new assignment and was

delayed. The pilot did not have an opportunity to query me (frequency congestion) so he

too was delayed. I am coordinating with safety vehicle about FOD removal, taxiing aircraft

to a new runway and shooting gaps between arrivals and departures on intersecting

runways. This is unsafe. This is horrible customer service.

I would recommend keeping Ground Control open from 0700 to 2100. In order to do that,

the culture of this facility would have to drastically change. One hour breaks and spot

leave trump safety and customer service.

Synopsis

Local Controller working Ground combined reported that hour breaks are common at this

facility and safety is being jeopardized. Controller was too busy at times and because of

this aircraft were delayed. Controller recommended keeping ground control open during a

specific time.

ACN: 1295901 (45 of 50)

Time / Day

Date : 201509


Place

Locale Reference.Airport : SJU.Airport

State Reference : PR


Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : SJU

Aircraft Operator : Corporate




Flight Plan : IFR

Mission : Ambulance

Flight Phase : Taxi

Route In Use : None

Airspace.Class C : SJU

Person

Reference : 1

Location Of Person.Facility : SJU.TOWER


Function.Air Traffic Control : Flight Data / Clearance Delivery







Events






Assessments




Narrative: 1

Aircraft X called for his clearance to ZZZ airport. His clearance was not available and I

informed the pilot that I did not have his clearance. After about 3 minutes the pilot called

again, and as I was trying to verify if the flight plan was in the system, the clearance

popped up and I issued the clearance to the pilot. I do not remember seeing the FRC (Full

Route Clearance) remark for a full route clearance on the strip I used to give the clearance

to the pilot. Within a few minutes after issuing the clearance, I noticed the strip was

removed from the system, I immediately reached out to the pilot informing him that his

clearance was removed from the system and that I was going to try to find out what had

happened.

I called ZSU flight data to find out what the problem was and the controller (whose initials

I do not remember) told me that he had removed the flight plan because he had two. I

told him I had only one in my system and he said that he would send me the other one,

and not to worry about it. I received the second strip and I did not look carefully to notice

that there was an FRC remark on the strip. I then inform the pilot that the clearance

remained the same and that his new squawk code was XXYY. Just short of departing the

local controller informed me that the strip still had an FRC remark on it, which without

thinking, I removed without questioning or informing the pilot that he had a full route

clearance. When I got home my supervisor called me and asked if I had forgotten to issue

the full route clearance to which I said no and informed me that the aircraft was on a

closed route (I believe it was L455, which apparently was closed for weather). I do not

know the outcome of the aircraft.

Regardless of how quick things might be done, and how incomplete a coordination is made

between controllers, we should always stick to the basics and read the entire strip looking

for changes prior to telling a pilot that his read back was correct, in order to assure the

safety of the pilots and the passengers in the NAS. A flag should have raised in my head

after noticing that there were two strips, which is usually an indication that something

changed and that a full route clearance (FRC) shall be issued.

Synopsis

An SJU Controller failed to issue a full route clearance after missing the note in the

remarks of the flight plan. Aircraft became airborne on a closed airway.

ACN: 1294768 (46 of 50)

Time / Day

Date : 201509


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model



Flight Plan : VFR

Mission : Ambulance





Person

Reference : 1















Events







Assessments




Narrative: 1

During an Active HAA (Helicopter Air Ambulance) mission I delivered a patient to the

[hospital]. After completing the mission and departing the area my dispatch said that

[Tower] notified them that I broke the TFR over the stadium for the football game that

was taking place. I was very surprised because earlier in the day I had checked the FAA

standard briefing website for TFR information and there was nothing on that page notifying

me of that TFR. I also have up to the minute XM weather/TFR information being sent

directly to my GPS, and it didn't show any TFR over the stadium. The next day there was

another college football game taking place at [a different college]. Foreflight, a third party

product said that there was a TFR over that stadium but again the FAA website said that

there wasn't. Even when the TFR became active it didn't say anything about it on the FAA

website. I feel that there is a gap in the system that could be either clarified or fixed. It

seems like the TFRs for football games are not being published as expected by pilots.

Synopsis

Bell 407 pilot reported he had a TFR incursion and stated the TFR was not listed on the

FAA briefing website. Both TFRs were for sporting events.

ACN: 1294332 (47 of 50)

Time / Day

Date : 201506

Environment

Work Environment Factor : Temperature - Extreme

Aircraft

Reference : X



Operating Under FAR Part.Other

Mission : Ambulance


Person : 1

Reference : 1

Location Of Person : Repair Facility


Function.Maintenance : Inspector









Person : 2

Reference : 2



Function.Maintenance : Lead Technician









Person : 3

Reference : 3



Function.Maintenance : Inspector










Events



Anomaly.Deviation - Procedural : Maintenance



Assessments






Narrative: 1

I work in a 145 Repair station as a hangar mechanic, and I was asked to go to assist in a

swashplate change on an AS350B3 that was stuck on the hospital landing pad due to a

swashplate shim protruding from the center of the swashplate. The repair took 11 days.

We had been working very long hours (10-14hrs daily) in very hot weather all outside on

top of the Hospital pad where the helo was stranded. During the swashplate change after

disassembly of the main gear box we noticed that the bolt holes had corrosion build up in

them and the ring gear had also been corroding due to bad sealant on the bolt heads, so

we ended up removing the entire assembly and changed out the epicyclic and housing at

the same time. During the reassembly of the housing and epicyclic, (we had been working

for 14 hours that day) we decided to call it and to get some rest. I left to go to my hotel

and came back in the morning to find that the epicyclic had already been installed into the

housing, however, during my RII of the installation I noticed that the gearbox and

epicyclic had been coated with Turco instead of mineral oil which is what is called out for. I

notified the lead and he said they had installed it after I left. So they came up to the pad

to confirm and ended up flushing the system out before we installed the rest of the mast

and components. The lead mechanic was instructing and helping to assemble the mast and

swashplate assembly (the Maintenance Manual (MM) reference was printed out and we

were going step by step). We had to take breaks often due to how hot it would get on top

of the hospital but the job got finished.

[Several months later] the helicopter was trucked in for a tail rotor strike. During a brief

incoming inspection and cleaning another mechanic noticed that the dust cover and or

boot that covers the top of the swashplate was missing.

During our maintenance ops, there were many people constantly calling to figure out when

we would be done which caused many distractions, so less or no phone calls during

maintenance ops on an Aircraft on Ground (AOG) aircraft would be immensely helpful. If

the aircraft is stuck on the helipad or in an area where it cannot be moved to a hangar,

putting up a temp shelter (roof tent) or something like that would help immensely with

less fatigue and possible heat stroke, which in turn leads to more mistakes and less work

time due to the time spent trying to cool down and regulate body temp and sunburn. No

pilot interaction during these maintenance ops would also help a lot, it makes our jobs as

mechanics a lot harder when we not only have supervisors and their bosses phoning us all

the time to then have the pilot ask how much longer.

Narrative: 2

This aircraft was removed from service and placed under unscheduled maintenance for

removable shims extruding from the swashplate on top of the hospital helipad. A

[contract] was submitted for outside help as the maintenance crew on staff had not

performed this job to a level of comfort. Maintenance support arrived for assistance. Upon

removal of the mast assembly, it was noted that the epicyclic gearbox and sun gear

assembly were corroded beyond limits, further increasing the workload on the [roof] of the

hospital in the middle of summer, requiring a full transmission replacement. Initially, we

were told that removing the aircraft from the hospital by crane was not the best option at

the time, as we were only to be performing a couple days' worth of work, but when the

corrosion was found, it would have taken the same amount of time to reinstall everything

needed to crane the aircraft as to put it back together to return to service. The removal,

disassembly, reassembly, and return to service took us 10 days of all mechanics working

over 10 hours per day. During this time I worked on and off with the mechanics

performing the maintenance, as I am the lead mechanic for the program and had other

priorities. During this 10 day event I called a safety stand down day on day 7 as the

maintenance crew was showing signs of heavy fatigue, both mentally and physically. The

installation, ground runs, and check flights were completed and the aircraft was returned

to revenue service. While I was not the primary mechanic on this job, I feel it necessary to

submit this as I did help and did not notice the issue.

[Over 2 months later] this aircraft was involved in a tail rotor strike at a scene call. This

aircraft was loaded on a truck and shipped to a repair station for maintenance required for

the tail rotor strike inspection. During acceptance inspection, it was noted that the

swashplate appeared to be missing the dust cover on top of the swashplate. I was notified

by my supervisor, and began researching this issue. After consulting the removal and

installation part numbers, it became apparent that the installed part number was not

effective for this aircraft. After consulting the maintenance staff involved, and looking at

the Illustrated Parts Catalog (IPC) for this install, we could not find the correct swashplate

in the IPC, and the only part number shown was the one that was installed. The repair

station has the aircraft at this time, and will make the repairs as necessary. This event

was an eye opener to all of us as we look back to all of the long hours that were put in to

get this aircraft back in service, and that sometimes we need to take a step back and look

at ourselves before we look at the work ahead of us.

In my opinion, there were multiple factors that lead to this incident. Maintenance staff was

pressured, both personally and by the customer, to provide an expedited service that

could not be met. Maintenance pressures were also felt from the heat during this time of

the year, on top of an aluminum helipad, with no shade available at the aircraft. The

airframe IPC played a large role in the incorrect ordering of parts, as the IPC is somewhat

vague when it comes to ordering parts for aircraft with different modifications installed

(i.e. dual hydraulics in this case). I believe this incident could have been avoided if the

aircraft had been removed from the hospital from the very beginning, removing the

pressures from the hospital on a direct level.

Narrative: 3

I was notified that an aircraft had been sent by ground transport to the Repair Station due

to a Tail Rotor strike. I was made aware that during the receiving inspection into the repair

station that it was discovered that the Main Rotor Swashplate assembly was missing the

top dust cover (boot). Later during this day it was also brought to my attention by the

Lead Mechanic that after discussing this situation with Mechanic that was currently on duty

that the Swashplate that is currently installed may be the incorrect assembly.

Due to a previous recent event, the swashplate had been replaced. The replacement was

due to a peel shim that was found during a preflight check that was partially ejected from

the top of the uniball. The work for this replacement was [accomplished several months

ago]. While attempting to order the replacement swashplate I was unable to find the

replacement part number for this assembly in the online AS350B3 Illustrated Parts

Catalog. I notified the lead mechanic to inform him that I was unable to find this part

number. After some discussion we both agreed that the Airbus Helicopter Technical

Representative should be called for support.

I immediately called the Tech. Rep. and explained my situation and that this was to be

installed on an AS350B3 with Dual Hydraulics. I was told that I would not find that part

number in the AS350B3 IPC and that I would need the part numbers found on the

Component Cards for the Rotating and Non-rotating Swashplates (sub-assembly part

numbers) and that he would send me a sheet that would give a breakdown of these part

numbers that would provide the Swashplate Assembly part number (Next Higher

Assembly) that was needed. This Swashplate was ordered and properly received into the

base. Before the work for the replacement of this Swashplate began, I voiced concerns

with the Lead Mechanic that although I have performed this maintenance tasking before

for a swashplate replacement on an AS350B3, it had been maybe as long as 6 years since

the last time I had done this and I had not done this task on an AS350B3 with Dual

Hydraulics. This coupled with the fact that this was a brand new base and that this

maintenance was to be performed on the roof of the hospital with temperatures that were

to be in the high 90's were also concerns that I voiced. The lead mechanic agreed that we

would need additional support. He made arrangements to have a mechanic experienced at

this procedure sent from another Repair Station and requested that I was to perform this

as OJT that was to be documented in the OJT book provided to the field mechanics.

Another experienced Mechanic was also sent for additional maintenance support.

Although another mechanic signed off this installation, the three mechanics, myself

included, involved in this installation shared equally the responsibility of this installation. I

provided the RII and at that time I should have reviewed the installation procedure again

with the two mechanics. I believe that each one of us were under the impression (although

now knowing it to be wrong) that because the assembly that came off did not require the

boot that this was still the case with new assembly that went on.

I have reviewed the procedure in the AS350B3 Aircraft Maintenance Manual (AMM) for the

installation of the swashplate onto the Mast Assembly again and it does not distinguish

between the different assembly types with either the required dust boot or a rain guard as

is found on the AS350B3's with dual hydraulics. The procedure does call out for the

installation of the boot and in retrospect I feel now that I should have questioned our

installation at this time. There is also nothing that I could find on the hard cards that

distinguish the installation of the rain guard as opposed to the lip ring used for the

installation of the dust boot. I feel the process for determining the part number for the

Swashplate assembly is convoluted and not in good practice. I should have questioned this

process at the time that I did not find the part number in the IPC.

I believe there were more challenges with this swashplate change and eventually the Main

Gearbox than normal in a field environment. This was a brand new base that was not

completely equipped yet to handle this type of heavy maintenance. The fact the work that

was to be completed on the roof of the hospital where the OAT was 95 to 100 degrees F

each day and that we were on a metal helipad was extremely challenging. The teardown of

the main gear box and Mast Assembly was completed in a small room on the roof of the

hospital just outside the elevator with no air conditioning or circulation of air. We worked

10 to 14 hours each day in order to reach our goals. Word was getting passed on to us

about some of the outside pressures to have the aircraft back in service and that this was

a new base and a new contract that was taken over and that this issues did not exist with

them.

Synopsis

Several Maintenance Technicians reported difficult working conditions that resulted in

maintenance errors including the possible installation of the incorrect part number.

ACN: 1292795 (48 of 50)

Time / Day

Date : 201509


Place

Locale Reference.Airport : RDU.Airport

State Reference : NC


Environment



Light : Daylight

Aircraft : 1

Reference : X

ATC / Advisory.TRACON : ROA





Flight Plan : IFR

Mission : Ambulance




Airspace.Class E : ZDC

Aircraft : 2

Reference : Y

Make Model Name : Small Aircraft, High Wing, 1 Eng, Fixed Gear



Airspace.Class E : ZDC

Person

Reference : 1





















Events




Detector.Automation : Aircraft RA




Assessments




Narrative: 1

We were flying on a Part 135 flight to ROA. There were four passengers onboard. I was the

assigned PIC for the flight and I was flying from the left seat. It was approximately XA:55

and we were in the terminal area of ROA and communicating with Roanoke Approach

control. We were at 6000 feet and were assigned vectors and told to expect the visual

approach to runway 34. Roanoke Approach control advised us of traffic at our one o'clock

position and 500 feet below us. We both attempted to visually locate the traffic. I adjusted

my TCAS range to 5 miles and could see the traffic on the TCAS display but was not able

to visually locate the traffic. We received an audible message to "monitor vertical speed,"

which I did. Shortly thereafter the TCAS issued a Resolution Advisory to "Climb". I

immediately disconnected the autopilot and began to climb. Within seconds we were clear

of the conflict. The First Officer notified ATC that we had just complied with the RA. Shortly

thereafter we observed the airport and were given the visual approach. We landed without

incident. There were no injuries or damage to the aircraft. I called our Chief Pilot to advise

him of the incident.

I don't believe that we could have handled the situation any differently. The TCAS

performed its function and we complied with the "RA". I believe that the Approach Control

facility should have vectored our aircraft further away from the other aircraft instead of

relying on our ability to see the traffic.

Synopsis

An air taxi crew at 6,000 ft was issued a traffic advisory at 5,500 ft by ROA TRACON on

vectors for ROA. The crew did not see the aircraft but responded to a TCAS RA CLIMB with

the traffic 500 ft beneath.

ACN: 1286321 (49 of 50)

Time / Day

Date : 201508


Place




Environment



Light : Daylight


RVR.Single Value : 10000

Aircraft

Reference : X





Flight Plan : VFR

Mission : Ambulance



Airspace.Class G : ZZZ

Person

Reference : 1
















Events








Assessments





Narrative: 1

I am an EMS helicopter pilot. While flying with a patient from a scene call [to the medical

center], I encountered two crop dusting aircraft in close proximity to my aircraft. I was at

500 feet AGL (Med crew requested lowest altitude due to patients severe head injury) a

crop duster aircraft flew 200 feet below me perpendicular to my flight path. I do not

believe the pilot of the other aircraft saw me at all. After this incident I climbed to 1000

feet AGL and [a few minutes later], I had a second crop duster aircraft fly under me, again

perpendicular to my flight path. As with the previous incident, I do not believe this pilot

saw my aircraft either. Because of my increased altitude, there was at least 700 feet of

separation between us and much less of a factor. Our current flight path flies right through

an area of high crop dusting activity. Because they do not have a common frequency,

there is no way to make advisory calls or communicate with the crop dusting aircraft.

Synopsis

AS350B3 helicopter pilot reported two NMACs with crop dusters during flight.

ACN: 1284059 (50 of 50)

Time / Day

Date : 201508


Place

Locale Reference.Airport : CRW.Airport

State Reference : WV


Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : CRW





Flight Plan : None

Mission : Ambulance

Flight Phase : Taxi

Component

Aircraft Component : Air/Ground Communication


Problem : Design

Person

Reference : 1
















Events








Assessments






Narrative: 1

I was parked at hospital helipad and attempted to contact Charleston tower on 125.7 to

get a Class C departure clearance to reposition for fuel. I tried 2 times with no answer

over the radio. This has happened many times over the years flying into all of the

Charleston area hospital helipads. After no contact was made I made sure all radios were

tuned correctly and volumes were appropriate, which they were. I then lifted off the

helipad and at 100 feet above the helipad I could hear the Tower talking to another

aircraft. Once that communication was complete, I immediately called the Tower and

asked to depart the helipad to land at a nearby airport FBO for fuel. I was then asked if I

had departed I said yes because I was flying above the helipad. Departing, which I later

learned from one person in the tower is as they defined, being greater than 200 feet

above the helipad elevation, which I was not when two way radio communication was

established. So I guess I should have said I lifted and not have said I had departed. After I

was given my clearance and actually did depart, I was asked to call a number to speak

with the Tower. I was flying the aircraft and asked the tower to standby until I landed to

give me the number. Once I called the number I was immediately talked to in an

aggressive and unprofessional manner! I introduced myself but the same was not done

until I had to ask who I was taking to, I was told the initials of the two who were on duty

but that's beside the point. The point is from time to time tower cannot be heard from

these hospital helipads. I do not take additional risk or disregard ATC instructions. I guess

the Tower could hear me on the helipad and told me to standby because of other

helicopter traffic but like I stated earlier I could not hear the Tower. Hopefully something

can be done to improve the communications at these hospital helipads.

Synopsis

A helicopter pilot preparing to depart a Charleston area hospital helipad attempted

clearance into CRW Class C, but could not hear ATC and so hovered at 100 feet until

cleared. ATC was upset that he took off, but communications from area hospital helipads is

poor.

Documents

Emergency Medical Service Incidents - ASRS · PDF fileEmergency Medical Service Incidents . ... learned that the airport was closed for runway resurfacing. ... go-around due to a coyote