Category Archives: Helicopters

Issues, Tips and New Technologies for the Emergency Medical Helicopter Case

The following was presented by Scott Brooksby at the ABA National Institute on Aviation Litigation in New York, New York, on June 4, 2015, concerning “Issues, Tips and New Technologies for the Emergency Medical Helicopter Case”:

Introduction

Why Are There So Many Helicopter Air Medical Crashes Causing Serious Injury or Death?

Prosecuting and defending helicopter crash cases is complicated and difficult.  This is particularly true in the cases involving helicopter emergency services flights (“HEMS”).  Pilot stress, fatigue, motivation to accept and accomplish a mission, weather conditions, including inadvertent encounters with Instrument Meteorological Conditions (IMC), varying unit technology, wide-ranging pilot training and flight time, differing qualities of dispatch decision making programs, all contribute to the complexity of HEMS flights, and the relative frequency of crashes related to HEMS flight.

According to the NTSB, which is charged with investigating every aviation accident in the United States, and many abroad, there were no fatalities in any 14 C.F.R.§ 121 accidents in 2010.  This despite some 17.5 million flight hours.  In 2011, there were 31 Part 121 accidents with no fatalities and 54 Part 135 accidents consisting of 16 fatal accidents and 41 fatalities.  (Review of U.S. Civil Aviation Accidents, Calendar Year 2011, Review of Aircraft Accident Data NTSB/ARA014/01, PB2014-101453).  This data excludes air medical operations conducted as part of general aviation.

Air medical operations are conducted under Parts 91 or 135 of Title 14 of the Code of Federal Regulations, depending on whether patients are being carried on board the aircraft.  Helicopter Emergency Medical Services (“HEMS”) missions en route to collect patients, or to collect organs, or to reposition aircraft after accomplishing patient transport operations, are generally conducted under Part 91.  Trips conducted to transport patients or organs on board are conducted under Part 135.  Some air medical helicopter operations, particularly for emergency medical services, are conducted by state or local government entities as public use flights, whether patients are on board or not.

A Statistical Overview of HEMS Accident Frequency and Type

Six air medical accidents occurred in 2011, two of which were fatal.  Id.  From 2002 through 2011, 41 percent of air medical accidents involving fixed-wing airplanes and 36 percent of air medical accidents involving helicopters were fatal.  Id.

HEMS accounted for about 80 percent of all air medical accidents during the ten-year period 2001-2011.  Id.  Against this backdrop, we examine medical accidents, specifically those involving helicopters, where in 2010 alone, there were 13 HEMS accidents, 7 of which were fatal.  From 2002-2011, 42 of the 118 HEMS accidents (36%) were fatal.  Id.

In 2011, there were three helicopters involved in air medical accidents in 2011.  The first accident involved a helicopter operating under Part 91, which encountered abnormal runway contact during a power-off landing resulting in substantial damage to the aircraft, but no injuries.  The second accident involved a helicopter operating under Part 135.  Substantial damages occurred when it impacted terrain during an autorotation following loss of power and all four occupants were fatally injured.  In the third accident, also operated under Part 135, a main rotor blade contacted the vertical stabilizer during engine shutdown, resulting in substantial damage but no injuries.

The pilots of these helicopters had an average total flight time of 11,935 hours, with an average of 1,355 hours in the type of accident aircraft.  The accident pilots were an average of 53 years old.  Id.

Six of the Seven HEMS fatalities in 2010 involved operations under Part 91.  From 2000 through 2010, 33 percent of HEMS accidents were fatal.  Most HEMS accidents occurred during airborne phases of flight and during 2010, all HEMS fatalities occurred during airborne phases of flight.

Between 2007 and 2009, air medical accidents were dominated by helicopters flying emergency medical service operations, rather than transfers of patients.  EMS flights in helicopters, under Part 91 regulations without patients on board had substantially higher accident rates than any other category of air medical flying.

While fixed-wing airplanes are more often used for interfacility transportation using established airport facilities, there are few accidents.  Between 2000 and 2009 there were few accidents and only 10 of them were fatal over the course of the decade.  (Review of U.S. Civil Aviation Accidents, Review of Accident Data, 2007-2009, NTSB/ARA-11/01, PB2011-113050)

It may be useful to breakdown the 31 accidents involving 32 helicopters in air medical operations between 2007-2009.  Eighteen were being operated under Part 91, thirteen under Part 135 and one as a public use flight.  Eleven of the accidents, involving 12 helicopters were fatal.  There was one public use fatal accident in 2008.  Collision with objects on takeoff or landing accounted for 7 of the 31 accidents but no fatalities.

Four of the five controlled flight into terrain accidents were fatal, including the crash of the Maryland State Police public use flight carrying accident victims on approach to Andrews Air Force Base.  Two of the three loss of control in-flight accidents were fatal, as were two of the three unintended flights into instrument meteorological conditions accidents.  The midair collision between two Part 135 helicopters in Flagstaff, AZ in June 2008 was also fatal to all on board.  All of the fatal accidents occurred during airborne phases, including en route, approach, maneuvering and emergency descent.  Id.

What Are The Typical Causes? 

In any aviation operation, pilot training and experience, and pilot judgment are some of the most important factors in safe flight.  With helicopter operations generally, and especially HEMS operations, pilot experience, training and judgment are even more critical because of the conditions they fly in, and the unparalleled need for speed.  Review of individual NTSB probably cause reports, NTSB factual data and other aviation industry data would tend to suggest that fatal and serious injury helicopter accidents are most often the result of a number of factors including loss of control, visibility issues, wire strikes, system component failure or post-impact fire.

Although some of these issues pose dangers during Part 121 operations, an argument could be made that they simply do not pose the same risks, largely due to obvious differences in the nature of the aviation operation, the equipment, altitude, avionics, take-off and landings from tightly controlled air-space and the use of aerodromes.  Another significant factor may be that Part 91 operations have no duty time restrictions.   (Special Investigation Report on Emergency Medical Services Operations, Aviation Special Investigation Report NTSB/SIR-06/01. PB 2006-917001, Notation 4402E, National Transportation Safety Board, January 25, 2006).  Fatigue has been shown to impair performance and diminish alertness.  (National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Fatigue, Safety Report NTSB/SR-99/01  (Washington, DC:  NTSB, 1999).

There is also wide variation in the nature and quantity of helicopter air medical pilot training.  From 2007-2009, for example, NTSB data suggest that the accident helicopter pilots’ median age was 54, ranging from 35 to 69.  Median total flight hours were 7,125 with a range from 2,685 to 18,000.  The median time in the type of accident helicopter was 375 hours, ranging from 11 to 4,241.  Id.

Review of any significant sample size from the NTSB aviation accident database shows that weather, particularly unanticipated entry into IMC, or pilot election to accept a mission with known adverse or deteriorating weather conditions is a major factor.  (See, e.g, case studies in Special Investigation Report on Emergency Medical Services Operations, Aviation Special Investigation Report NTSB/SIR-06/01. PB 2006-917001, Notation 4402E, National Transportation Safety Board, January 25, 2006)(Stanislaw P.A. Stawicki, MD, Hoey, Brian A, MD, Portner, Marc, MD, Evidence Table:  Summary of Aeromedical Incidents (2003-2012) OPUS 12 Scientist, 2013 Vol. 7, No. 1.

For example, on March 25, 2011, a Eurocopter AS350B3, registered to Memphis Medical Air Center crashed while heading directly into a weather cell, killing the pilot and two flight nurses.  The NTSB ruled that attempting to fly into adverse weather, with localized adverse night IMC, was the likely cause of the crash.  The shift pilot suggested parking the helicopter, but the active duty pilot insisted there was enough time to make it, believing he had about 18 minutes to beat the storm and return to base.  The shift pilot later learned the flight was about 30 seconds from arrival when the helicopter crashed.  Similar scenarios involving poor judgment, adverse weather conditions, and lack of outside, objective input on whether a mission should proceed are frequent NTSB probable cause factors.  Id.

Statistics suggest that such variations in flight time and the corollary impact on experience and judgment may be significant factors in the number of crashes.  Id.  HEMS operations often make use of helicopters, and they use unimproved landing sites at accident scenes and helipads and hospitals or medical facilities.

Loss of control in flight was the most common event for both fatal and non-fatal helicopter crashes, followed by collisions on takeoff or landing and system component failure of the power plant.  Even though HEMS pilots may have thousands of flight hours, and be some of the best helicopter pilots in the world, owners and operators should continuously emphasize the consistent causes of HEMS crashes and adapt training programs to focus on those causes.

Possible Improvements

One of the NTSB’s “Most Wanted” Transportation Safety Improvements in 2015 is the enhancement of public helicopter safety.  However, many of these suggestions could apply to non-public use helicopter activities under Part 135 or Part 91.  http://www.ntsb.gov/safety/mwl/Pages/default.aspx   (Last visited April 2, 2015).

Since 2004, the NTSB has investigated more than 130 accidents involving federal, state, and local public helicopter operations, including the 4 mentioned above.  Fifty people were fatally injured and 40 seriously injured.  Id.  What can be done:

  1. Operational factors including the development and implementation of safety management systems hold great promise. In particular, flight risk evaluation programs and formalized dispatch and flight-following procedures which relieve pilots of decision making under stressful or fatiguing conditions.  Also promising, are scenario-based training which exposes pilots to inadvertent flight into IMC.
  1. Investment can be made in advanced technologies. The NTSB has recommended that helicopter operators install radio altimeters, night vision imaging systems and terrain awareness warning systems.
  1. Finally, the NTSB advocates for crash-resistant flight recorder systems for all aircraft.

Although these items are on the NTSB’s Wish List for 2015, at least as to the enhancement of safety involving public use helicopters, a 2006 NTSB report discusses what are essentially the same improvements as recommended for air medical services.  (Special Investigation Report on Emergency Medical Services Operations, Aviation Special Investigation Report NTSB/SIR-06/01. PB 2006-917001, Notation 4402E, National Transportation Safety Board, January 25, 2006).  While valuable safety improvements have been recognized for some time, they may not be as actively implemented as necessary.

Case Notes

In what may be one of the first cases of texting and flying, a helicopter emergency medical services flight case involving pilot texting was settled in April, 2013.  The NTSB conducted a public hearing and concluded the pilot sent and received 240 text messages during his shift, including three sent and five received while the helicopter was in flight.  The distracted pilot failed to realize that he had inadequate fuel to complete the flight, which crashed near Mosby, Missouri on August 26, 2011 due to fuel starvation.  The case is Bever, et al. v. Estate of Freudenberg, Clay County, 11Cy-10505, Tacoronte, et al. v. Estate of Freudenberg, Clay County, 11CY-CV10179.  The case was settled for a reputed $8,000,000.

On September 27, 2008, “Trooper 2,” a HEMS flight operated by the Maryland State Police, crashed several miles short of the runway at Andrews Air Force Base while executing an ILS approach with two motor vehicle accident victims on board. The accident killed the pilot, the Maryland State Police paramedic, a borrowed paramedic from the landing site, and one of the two MVA victims. The other MVA victim—the sole survivor—was thrown from the wreckage at impact and suffered severe injuries. Despite the fact that the helicopter had received radar vectors onto the final approach course and was equipped with ADS-B (which provides position data every second), the survivor languished in a pond of Jet-A at night for two hours before being found. The United States was joined in the subsequent litigation, and all cases ultimately were settled by Maryland and the United States for approximately $15,000,000.

The NTSB recently published its report on an accident near Talkeetna, Alaska, on March 30, 2013, in which a Eurocopter AS350 B3 helicopter,1 N911AA, impacted terrain while maneuvering during a search and rescue (SAR) flight. See NTSB/AAR-14/03 (November 14, 2014). The airline transport pilot, an Alaska state trooper serving as a flight observer for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the helicopter was destroyed by impact and postcrash fire. The helicopter was registered to and operated by the Alaska Department of Public Safety (DPS) as a public aircraft operations flight under 14 Code of Federal Regulations (CFR) Part 91. Instrument meteorological conditions (IMC) prevailed in the area at the time of the accident. The flight originated at 2313 from a frozen pond near the snowmobiler’s rescue location and was destined for an off-airport location about 16 mi south.  The NTSB determined the probable cause of the accident was the pilot’s decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. Also causal was the Alaska Department of Public Safety’s punitive culture and inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training. Contributing to the accident was the pilot’s exceptionally high motivation to complete search and rescue missions, which increased his risk tolerance and adversely affected his decision-making.

 

In Lease Agreements With Provisions Requiring the Consent of the Lessor, Consent May Not be Unreasonably Withheld, Unless There is an Express Provision Stating Otherwise

Olson Brooksby works with many commercial industries, including airline owners and airline insurers, regarding lease agreements.  A common issue in lease agreements is whether the lessee is totally at the mercy of the lessor if there is a provision in the lease that requires the lessor’s consent.  May a lessor unreasonably withhold consent?

Under Oregon law, a lessor may not unreasonably withhold consent to a lease provision.

Take this hypothetical, for example.  Let’s say that there is a provision in the lease that requires the lessor’s consent before the lessee can fly the plane over a certain number of miles.  What if the lessee unexpectedly needs to exceed the mileage in that lease provision and the lessor refuses to consent?  Under Oregon law, a lessor may not unreasonably withhold its consent.  To do so would be a violation of the implied covenant of good faith and fair dealing. The key issue is what is “unreasonable”?  If the lessor proffers a reason that would seem objectively reasonable to an average juror, the lessor has met its burden and the lessee probably may not fly the plane beyond the agreed-upon mileage amount.

The standard is whether an objectively reasonable juror would believe that the lessor’s withholding of consent was unreasonable.

Oregon courts have held that every contract includes an implied covenant of good faith and fair dealing, also known as a “duty of good faith”.  See Uptown Heights Associates v. Seafirst Corp., 320 Or 638, 645, 891 P2d 639 (1995); Pacific First Bank v. New Morgan Park Corp., 319 Or 342, 344 n 1, 876 P2d 761 (1994) (Oregon courts use the terms “duty of good faith” and “duty of good faith and fair dealing” interchangeably).  This covenant implies that neither party will engage in any act that will “have the effect of destroying or injuring the right of the other party to receive the fruits of the contract.”  Perkins v. Standard Oil Co., 235 Or 7, 16, 383 P2d 107, 383 P2d 1002 (1963) (quoting 3 Arthur Linton Corbin, Corbin on Contracts §561, at 278 (1960)).  The Oregon Supreme Court has “sought through the good faith doctrine to effectuate the reasonable contractual expectations of the parties.”  Pacific First Bank 319 Or at 351 (internal quotation marks and citations omitted).

The lessee has an objectively reasonable expectation that the lessor will consent, especially if the lessor has no objective reason to refuse consent.  See Hampton Tree Farms, Inc. v. Jewett, 320 Or 599, 616, 892 P2d 683 (1995) (“jury could find that [seller’s] unilateral action in discontinuing to supply logs frustrated [buyer’s] objectively reasonable expectation”).

The lessor must act in good faith and within the bounds of the “objectively reasonable expectations” of the parties.  Uptown Heights Associates, supra.  The express terms of a contract help to define the objectively reasonable expectations of the parties.  Uptown Heights Associates, supra; see Pacific First Bank, supra; Stevens v. Foren, 154 Or App 52, 58, 959 P2d 1008 (1998) (“[t]he duty of good faith and fair dealing cannot contradict an express contractual term, nor does it provide a remedy for an unpleasantly motivated act that is permitted expressly by contract”).  Reasonable expectations include the right of either party to further its own legitimate business interests.  U.S. Genes v. Vial, 143 Or App 552, 559, 923 P2d 1322 (1996).

If there are consent provisions in a lease, it is best if there is an express contractual provision requiring the parties to act in good faith. 

It is best if there is an express contractual provision of good faith, but if there isn’t one, you can rely on the common law above to argue that the lessor, by unreasonably withholding consent, is not exercising good faith and fair dealing, which is implied under the contract.  Pollock v. D.R. Horton, Inc.-Portland, 190 Or App 1, 12–13, 77 P3d 1120 (2003).

The duty of good faith and fair dealing applies to lease agreements implicitly, even if there is not an explicit provision requiring good faith. 

In Pacific First Bank, 319 Or at 353, a landlord-tenant case, the Oregon Supreme Court held that the duty of good faith and fair dealing applies to lease agreements.  The court cited Milton R. Friedman, 1 Friedman on Leases § 7.303e2 (3d ed 1990), which notes that, “there is a rapidly growing minority to the effect that if [a] lease states ‘tenant may assign only with landlord’s consent’ or ‘tenant may not assign without landlord’s consent’ there is engrafted on this language by implication the phrase ‘which consent shall not be unreasonably withheld’”.  Pacific First Bank, 319 Or at 353.  The only way that the lessor could get around this is if there is a “’freely negotiated provision in the lease’” giving the lessor “’an absolute right to withhold consent’”.  Id. (quoting Restatement (Second) of Property § 15.2(2) (1977 & 1993 Supp) (emphasis added to the Restatement quotation by the Pacific First Bank court).

The Pacific First Bank case involved a tenant who had merged into its wholly owned subsidiary and a bank, the lessor, who refused to consent to the transfer and who argued that, under the terms of the lease, transferring the lease required the bank’s prior written consent.  Id. at 344.  The court found in favor of the tenant noting that, although there was a term in the lease that gave the lessor “a unilateral, unrestricted exercise of discretion,” in regard to the lease transfer provision, there was also a term in the lease that provided that the bank would “’not unreasonably withhold its consent to a sublease to a tenant’”  Id. at 354 (emphasis added by the Pacific First Bank court). 

It would thus be helpful if there is a term in the contract providing that the lessor cannot unreasonably withhold its consent—particularly if the lease also includes a term that gives the lessor a unilateral, unrestricted exercise of discretion in regard to the particular provision at issue.  However, in the absence of a unilateral, unrestricted exercise of discretion provision in favor of the lessor, it is not necessary to have a term providing that the lessor will not unreasonably withhold consent, given the court’s Friedman quotation above (“there is engrafted on this language by implication the phrase ‘which consent shall not be unreasonably withheld’”.  Id. at 353 (quoting Friedman, supra).

The lessor’s exercise of consent is thus tempered by the lessor’s duty of good faith and the lessor must not “unreasonably restrain” the lessee’s ability to conduct business in a reasonable and efficient manner.  Carey v. Lincoln Loan Co., 165 Or App 657, 670 (2000), aff’d, 342 Or 530 (2007).  In other words, the provision regarding the lessor’s consent is “not * * * absolute” or subject to the lessor’s “’whim.’”  Id.

 

New FAA Air Traffic Organization Policy Order to Establish Air Traffic Organization Safety Management System

FAA

Introduction

Federal agencies, such as the Federal Aviation Administration (“FAA”), a branch of the U.S. Department of Transportation, are continuously working to improve air safety, and the enabling legislation for such agencies provides them with rulemaking power to accomplish the goal of improved safety.  With the recent series of commercial airline crashes, air safety is once again a source of anxiety for many air travelers.  Although statistically, decade after decade, air travel continues to prove itself as by far one of the safest modes of travel, air crashes capture the attention of the public in a way that is uniquely gripping as compared to other transportation disasters.  The recent commercial crashes, MH 370 on March 6 (location unknown), MH 317 on July 17 (Eastern Ukraine), Trans Asia Airlines flight GE 222 on July 23 (Penghu Islands) and Air Algerie flight 5017 on July 24 (Northern Mali) collectively represent approximately 700 fatal injuries to passengers and crew in the space of 138 days.

Although none of these incidents occurred inside United States-controlled airspace, parts of U.S. Airspace are unquestionably some of the busiest in the world.  Regulation and control of U.S. Airspace is controlled by federal law which preempts state law in all such matters.

On May 30, 2014, the FAA issued Order JO 1000.37A, entitled “Air Traffic Organization Safety Management System” (“Order”).  The Order will take effect on September 1, 2014.  This will provide a brief overview and summary of key aspects of the Order.

The mission of the Air Traffic Organization (“ATO”) is to provide a safe and efficient series of air navigation services in the National Airspace System and in the United States-controlled international oceanic air space.  This includes communications, navigation, surveillance and air traffic management services.  The Order specifically establishes the Safety Management System (“SMS”) as the foundation upon with the ATO’s safety efforts are conducted and measured.

Background

The SMS is a multidisciplinary, integrated, and closed-loop framework used to help maintain safe and efficient air navigation services and infrastructure.  The Order requires the ATO SMS to be a framework for three specific areas:

  1. The development of safety policy and processes
  2. The promotion of a safety culture that identifies and reports activities that are potentially or actually detrimental to system safety; and
  3. The identification, continuous monitoring, auditing, and evaluation of hazards and the assessment and mitigation of safety risk within the National Airspace System (“NAS”) and United States-controlled international/oceanic airspace.

Structure of The Safety Management System

The four structural components that make up the SMS are

  1. Safety Policy.  This contains the requirements, standards and guidance to establish and execute SMS and promote a positive safety culture.
  2. Safety Risk Management.  This contains the processes and procedures established and followed ty ATO safety practitioners to identify hazards, analyze and asses risks.
  3. Safety Assurance.  This consists of the processes and procedures within the ATO SMS that ensure the ATO is operating according to expectations and requirements.  Safety Assurance provides validation of SR< efforts for proper operations, systems and equipment and identification of adverse safety trends.
  4. Safety Promotion.  Communication of proper safety practices through advocacy of the principles of a positive safety culture, employee training and compliance with ATO orders.

Conclusion

The bulk of the contents of the Order provide the intended mechanics for implementation and execution of the SMS and are beyond the scope of this summary.  However, with the skies becoming ever more crowded and the recent concerns over pilot fatigue, deficient CRM with some airlines, fly-by-wire and ever more complex aircraft, SMS appears to be a step in the right direction.  Whether the framework and structural components can be executed remains to be seen.

Olson Brooksby PC maintains an active aviation practice including the defense of aircraft and component part product liability claims and negligence claims resulting in personal injury and property damage and aviation related commercial disputes.

 

To curb medical helicopter crashes, focus on pilot haste, experience

Modern healthcare capture
Helicopter Emergency Medical Services crashes

Here’s an opinion piece by shareholder Scott Brooksby,  published in the June 10 issue of Modern Healthcare:

To curb medical helicopter crashes, focus on pilot haste, experience

A dramatic national conversation erupted recently following a U.S. National Transportation Safety Board finding that smart phone texting was a contributing factor in the crash of a fatal medical-helicopter flight in 2011.

The discussion has concentrated on everything from connecting the event to the dangers of texting while driving to calls for a ban on texting by pilots in air medical operations.

Absent from the discussion, however, is a larger issue that’s well recognized by helicopter industry safety organizations, and what should be of great concern for hospital administration and other organizations that contract emergency helicopter services.  The issue has to do with the egregiously high incidence of fatal and critical Helicopter Emergency Medical Services (HEMS) crashes, and resulting personal injuries.

In comparison to virtually every other type of commercial aviation, there is an inordinate rate of accidents within medical helicopter aviation, with the 2010 NTSB data proof in point.

Essentially, NTSB segregates aviation operations into hundreds of categories, the largest being all U.S. major domestic air carrier flights.  In 2010, NTSB reported only 14 accidents among major air carrier aviation, none of which were fatal.  By contrast, in 2010 there were 13 HEMS accidents, including seven fatal crashes.

Medical helicopter pilots are heroic and driven individuals who are among the best-trained and highest-skilled pilots in the world and fly what arguably are the most dangerous missions outside of military aviation.  HEMS pilots possess the grit and courage to go forth in dangerous conditions any time of night or day, in icy conditions or great heat, in storms, in densely trafficked urban controlled airspace, and remote uncontrolled airspace.

The most dangerous occupation

Operating without the benefit of formal flight plans with takeoffs and landings in uncontrolled locations ranging from roads to ball fields to the tops of buildings, the challenge is incredible.  Speed is critical.  But it comes with great risk.  In fact, according to a University of Chicago report, crewing a medical helicopter is the most dangerous profession in America.

Clearly it takes a special individual to accept the challenge.  But according to the International Helicopter Safety Team, the same attributes of risk tolerance, confidence and dogged determinism required of a HEMS pilot commonly are the very factors that, when excessive, lead to helicopter pilot error.

But what complicates the issue of haste to meet critical needs is the fact that the majority of HEMS accidents occur not when pilots are ferrying a patient to emergency treatment, but instead take place when pilots are rushing to the scene to pick up a patient, or the transportation of organs.

NTSB data shows that fully 58 percent of the 31 medical flight accidents occurring from 2007 to 2009 took place when the HEMS aircraft were en route to pick up an injured patient, or involved organ transport organs. Only 42 percent of HEMS accidents occurred with patients on board.

Haste and pilot error under harrowing conditions is exacerbated in the case of less experienced HEMS pilots.  Although on the whole HEMS pilots rank among the most experienced and capable pilots in the world, NTSB records indicate that flight hours of HEMS pilots not involved in accidents have logged 19 times as much air time in a particular aircraft as those involved in accidents.

Managing contract helicopter risk

Since 2005, there has been an increasing call for greater safety requirements in HEMS aviation, focusing largely on navigation equipment and flight dispatch and monitoring systems.  We expect to see continued progress in that area.

In the meantime, to reduce the incidence of HEMS crashes as well as to exercise prudent risk management, here are some steps for hospital administrators to consider:

–        Review your HEMS contractor pilot training program, with a preference for programs that not only meet, but exceed, FAA compliance levels;

–        Request documentation of contractor aviation risk assessment programs, and review the specific crew checklist parameters to assess risk level of each flight;

–        Stipulate that pilots have a minimal level of flying hours on the specific type of aircraft to be used in life flight operations;

–        Stipulate that pilots have a certain level of military flying service, or equivalent civilian training;

–        Review pilot histories and encourage condition-specific training that corresponds to local conditions; and

–        To limit claims against your hospital or organization, ensure that your HEMS contracts contain solid indemnity provisions.

Although the tragic human consequences of a fatal medical helicopter crash are clear, there’s less recognition of the massive risk of litigation, which while principally focused on the flight service company easily can become a deep, years-long issue for the contracting hospital organization.

HEMS operators are the first line of defense in one of the greatest challenges of emergency care, operating under diligent training execution and best principles of safe flight as established by the FAA and contractor safety policies.  However, perfection is an aspiration, and recognizing the record of accidents, hospital organizations should look beyond smart phone bans to limit the occurrence and risk of medical helicopter accidents.

 

 

Variables that can affect burn injury cases

Most experienced defense lawyers know that the variables in burn injury cases prevent anything resembling a guarantee of a good result.  The following variables can affect the outcome of a case, including the potential financial exposure that a defendant or its insurer or worker’s compensation carrier may face:

– the different types of skin grafts and skin graft surgical procedures commonly involved in burn cases;

– whether, in high total body surface area (tbsa) burns, complete excision and grafting can be completed in a single principal procedure;

– the treatment technique, surgical technique and treatment philosophy of the physician; and

– the relative size of the burn center, as larger centers tend to be able to perform certain procedures–not because of greater skill, but because of the size and number of  surgical teams necessary.

Skin Graft Classification and Skin Graft Surgical Procedures

In burn injury cases, surgical removal (excision or debridement) of the damaged skin is followed by grafting.  The grafting is designed to reduce the course of hospital treatment and improve function and cosmetic appearance.  There are typically two types of skin grafts–mesh grafts and sheet grafts.  A less-common, third type of graft is a composite graft.

Mesh Grafts

Mesh grafting is known as partial-thickness grafting, or split-thickness grafting.  With mesh grafting, a thin layer of skin is removed from a healthy part of the body, known as the donor site.  It is processed through a mesher, which makes apertures into the graft. The graft then becomes mesh-like, allowing it to expand approximately nine times its original size.  Such grafts are used to cover large areas and the rate of auto-rejection is lower.  Harvesting of these grafts from the same site can occur again after as little as six weeks.  The surrounding skin requires dressings and the donor site heals by reepithelialization.

Using a dermatome, the surgeon usually produces a split-thickness graft which is carefully spread on the bare area to be covered.   It is held in place by a few small stiches or surgical staples.   The graft is initially nourished by a process called plasmatic imbibition in which the graft drinks plasma.  New blood vessels begin growing from the recipient area and into the transplanted skin within 36 hours in what is called capillary inosculation.  To prevent accumulation of fluid, the graft is frequently meshed by making lengthwise rows of short interrupted cuts, each a few millimeters long, with each row offset to prevent tearing.  This allows the graft to stretch and more closely approximate the contours of the affected area.

Sheet Grafts

In the alternative, a sheet graft, which is a full-thickness graft, involves pitching and cutting away skin from the donor section.  Sheet grafts consist of the epidermis and entire thickness of the dermis.  Sheet grafts must be used for the face, head and hands because contraction must be minimized.  If sheet grafting is necessary but the donor sites are insufficient, the outcome is likely to be less satisfactory, and the financial exposure in such cases will be higher.

With sheet grafting, the donor site is either sutured closed directly or covered by a split-thickness graft.  Sheet grafts are more risky in terms of rejection, yet counter-intuitively leave a scar only on the donor section.  Sheet grafts also heal more quickly and are less painful than partial-thickness grafting.

Sheet grafting is usually difficult in severe aviation or manufacturing burns because those involve high-percentage tbsa burns and donor sites are therefore limited.

Composite Grafts

The third type of graft, a composite graft, is a small graft containing skin and underlying cartilage or other tissue.  Donor sites would include the ears and other cartilage to reconstruct, e.g., nasal rim burns.

In High TBSA Burns, When Immediate, Complete Excision and Grafting is Completed in a Single Procedure, Damages Amounts May Be Lower.

In cases involving clearly severe, high tbsa burns, whether full or partial thickness, immediate, complete excision and grafting is usually indicated.  If immediate excision and grafting is complete–that is, done in a single procedure–a much larger surface area surgery can be completed with less blood loss.  This minimizes transfusion needs and dangers and also speeds physiological restoration.

Furthermore, an immediate, complete excision and grafting procedure can often allow use of good skin for grafting that would otherwise need to be excised.  If the procedure is not done immediately, less skin may be available for grafting.  In other words, skin that otherwise may have been healthy and usable when the plaintiff was first admitted to the hospital may die if the procedure is not done immediately, particularly if that skin is close to the burn site.

Immediate, complete excision and grafting also cuts down on the number of procedures and allows important vascular redevelopment to begin occurring sooner and supplying the graft locations with blood flow, which is essential to healing.

 The Treatment Technique, Surgical Technique and Treatment Philosophy of the Physician Can Be Outcome-Determinative

The simple fact is that some surgeons are more skilled than others, so the outcome may be better or worse depending on the skill of the physician.

There are also some advances in burn surgery that particular physicians are able to employ.  For example, in the most serious burn cases, grafts may be taken from other animals.  Such grafts are known as heterografts and, by design, they serve as temporary dressings that the body will unquestionably reject within days to a few weeks.  They are used in severe cases to reduce bacterial concentration of an open wound and reduce fluid loss.

Additionally, some surgeons are able to use cell cultured epithelial autograft (CEA) procedures, which involve removal of skin cells from a patient and the growth of new skin cell sheets in a lab.  Although the new sheets will not be rejected, they are typically only a few cells thick and do not stand up to trauma.  As a result, many such grafts do not take and the procedure must be repeated or an alternate procedure employed.

Furthermore, some physicians prefer to do more sheet grafting versus mesh grafting.  The physicians who prefer mesh grafting like it because they can cover much larger areas in a shorter period of time.  Conversely however, mesh grafting requires more revision surgeries, more of a risk that the grafts don’t take, and more contraction, which is disfiguring and requires further surgery.

Different groups of surgeons have their own philosophies and cultural preferences.  In Portland, Oregon, for example, there is one group of approximately five, highly-skilled burn surgeons who staff the Oregon Burn Center at Emanuel Hospital.  Due to the relatively small size of the burn center, they tend to wait four to seven days before conducting major graft procedures so that they can have a better assessment of the full extent of the injury.

The Relative Size of the Burn Center Can Be Outcome-Determinative

Larger burn centers, such as the ones at UC Davis or Harborview in Seattle, do not necessarily provide better treatment, but they are typically capable of complete excision and grafting at admission when there is a high percentage of the total body that sustains full-thickness burns or a combination of full-thickness and lesser degree burns.  This is a function of burn center size, not the skill of the physicians.  A full excision and grafting procedure is lengthy and generally requires two full surgical teams and at least two attending physicians and two assistant surgeons.  This type of procedure is generally not possible at relatively smaller burn centers such as the Oregon Burn Center.

Using Variables in Burn Cases to Assess Case Value and Adequately Prepare

The variables discussed above vary from case to case.  It is important to assess each one when valuing a burn injury case in order to determine the defendant’s likely exposure and prepare adequately for productive settlement discussions and, if absolutely necessary, trial.

 

An Introduction to Burn Injury Significance and Burn Centers

Burns Are Significant Injuries and Can Lead to Some of the Highest Jury Verdicts

Olson Brooksby appreciates the potential high-exposure value of burn injury cases.  Scott Brooksby has significant experience in serious, total body surface area (tbsa) burn injury and wrongful death cases.  Our lawyers understand the delicate nature of large burn injury cases and work to minimize exposure to our clients.

Defendants potentially subject to burn injuries should employ best safety practices and make every attempt to avoid such injuries.  Burns are one of the most serious injuries in personal injury cases.  They may be the result of chemical fire or exposure, explosions, paints, solvents, or conventional fire.  Sometimes burns are the result of contact with hot equipment or other product liability related events.  The defense of serious burn injuries, including those related to aviation, product liability and heavy manufacturing is a large part of the defense practice of Olson Brooksby.  A bad burn case in an aviation or heavy manufacturing accident, or as the result of a product liability defect can easily present high financial exposure to manufacturers and/or insurers.  Settlement exposure can climb into the millions or tens of millions, with verdicts at least as high.

Even when there appears to be a strong defense, defendants should not underestimate the overwhelming sympathy a jury will feel when it sees a burn victim, particularly with serious facial burns or burns to the extremities.  A good plaintiff’s lawyer will ask the jury to consider things like the profoundly disfiguring effects of a bad facial burn and the pain that everyday exposure to sunshine will cause its victim for life, or the lifelong gawking stares it will draw.

Similarly tragic are severe burns to the hands, which cannot be restored to even near full function or pre-burn aesthetics and result in pain every time the victim is touched.  When liability is clear, burn cases should be settled because, unlike other personal injury cases, deformities caused by burns can incense juries to the point where they cannot put their emotions aside.  The result can be verdicts in the millions or tens of millions, including punitive damages (particularly if children are involved or there is perceived recklessness).  Although the amount of burn verdicts used to depend on the region of the country where the case originated, such verdicts are now generally high in every jurisdiction.

If the burn injury case must be tried, it must be done with great sympathy for the victim  and careful attention to the medical aspects of the case, including future treatment, which may last decades and cost into the six or seven figures.

When trying a burn injury case, it is important to know where the injury occurred.  If a plaintiff has to be air lifted to a burn center, that can radically change the extent of the injury.  Similarly, it is important to know the details of the burn center where the plaintiff was treated because that can also change the extent of the injury and thus affect the jury verdict amount.

The Location of the Accident Can Change the Extent of the Injury and the Jury Verdict

In those industries where serious conventional burns are common, such as aviation disasters or steel or metal manufacturing, “serious” can arbitrarily be defined as full-thickness burns over 20% or more of the tbsa.  The location of a burn center and the length of time to transport the victim to the burn center can be outcome-determinative.  This is also particularly true where babies and children or those over sixty-five are the victims, or where there are serious burns to the face, head, extremities, or internal organs.

Manufacturers and insurers obviously do not choose where burn centers are located.  After an accident, first responders will obviously make needed decisions about transport.  Most heavy manufacturing, including that of aviation hot section components, is done near large metropolitan areas that typically have at least one burn center.  Perhaps some of the greatest danger lies in cases in remote areas where individuals are subject to burns from allegedly defective products.  For example, a person camping in a remote area of the Western United States who is badly burned by kerosene at a remote campsite may not be able to reach a burn center for hours.  There may be no cellular phone service and a helicopter ambulance may have to be dispatched from hundreds of miles away.

Depending on the severity and tbsa burned, the size and related capabilities of the burn center will have a direct impact on the plaintiff’s recovery, and consequently, the ultimate exposure to the manufacturer and/or insurer in any settlement or verdict.

All Burn Centers are Not the Same–They May Have Varying Treatment Philosophies, Training and Capabilities

The size of the burn center can also be outcome-determinative because smaller centers, such as the Oregon Burn Center at Emanuel Hospital, are generally not large enough to perform a full excision and grafting in high tbsa burn cases.  A full excision and grafting is where they do all of the procedures at once instead of one at a time.  Some burn physicians believe that, depending on the case, better outcomes are achieved through full excision and grafting in high tbsa burn cases.

There are approximately 45 regional burn centers in the United States.  Verification of burn centers is a joint program administered in the form of a rigorous review of the applicant centers by the American Burn Association (ABA) and the American College of Surgeons (ACS).  Many states do not have a regional burn center and most states have only one or two.  California has the most, with seven.  Most burn centers are run by a single group or an extremely limited number of groups of burn surgeons who practice at the facility.

Unlike hospitals, burn centers do not typically extend general privileges to physicians.  Most burn surgeons have been trained as general surgeons, and then have gone on to receive additional specialized training in burns.   Along the population corridor running down I-5 between Seattle and Davis, California there are three verified regional burn centers, one each in Seattle (Harborview), Portland (The Oregon Burn Center at Emanuel Hospital), and The UC Davis Regional Burn Center.

Training and available resources vary from center to center.  Burn centers also tend to have more pronounced treatment philosophies and cultures because they are staffed by relatively few surgeons who generally practice in the same group or just a few groups.  However, although burn center practice varies, it is imperative that those who are seriously burned reach a regional burn center as soon as possible because specialized treatment is inarguably outcome-determinative

The mechanics of injury, lots of fire, accelerant, and contact with temperatures in excess of 1,000 degrees are factors that are considered when determining whether burns are graftable from point of admission.  In any serious burn case, most intermediate facilities such as a conventional hospitals will seek to transfer a seriously burned patient, almost always by air, to a regional burn center as soon as stabilization occurs.

 

NTSB Releases Statistics on Aviation Fatalities in 2011

The National Transportation Safety Board is a unique federal agency.  It is not a federal executive branch agency.  Rather, it is congressionally chartered with a single aviation mandate: to investigate every aviation accident in the Unites States, determine the probable cause of the accident, and make recommendations to help protect against future accidents.  See 49 U.S.C. §§ 1131, 1132, 1135 (Lexis Nexis 2006 and Supp. 2011).  Although the full extent of the operational and investigative methods of the NTSB are beyond the scope of this article, 49 U.S.C. § 1154(b) prohibits litigants from using the final probable cause report prepared by the Board in any manner.  However, the NTSB has a team of investigators in different specialty areas who prepare factual reports that do not involve conclusions regarding the cause of the crash.  Use of these reports depends on the particular judge’s rulings on the rules of evidence, particularly Rule 803(8).

The NTSB recently released aviation data and statistics for transportation fatalities in 2011, including aviation.  According to the NTSB, there were 494 aviation fatalities in 2011.  Those fatalities are broken down by area as follows:  General Aviation (444); Air Taxi (41); Foreign/Unregistered (9); Airlines (0); and Commuter (0).

Olson Brooksby PC maintains an active aviation accident and aviation component part product liability defense practice.  For further information, please contact our office.

NTSB Hearing on Medical Helicopter Crash Considers Pilot Texting Ban

Close up of judge raising gavel in courtroom

The NTSB held a hearing on a fatal medical helicopter crash that took place in 2011.  After finding that smart phone texting was a contributing factor in the fatal crash, the NTSB recently considered a ban on pilot texting.  It is surprising that such a regulation is not already in place or under more serious consideration.  Because there was evidence that the pilot had not been texting during the 19 minutes before the crash, however, the NTSB did not take any formal action on such a ban.

This is part of a larger issue that demands attention — the egregiously high incidence of fatal and critical Helicopter Emergency Medical Services (HEMS) crashes, and resulting personal injuries.

Olson Brooksby practices a wide variety of aviation law.  We have experience representing airlines, aviation insurers, aviation product manufacturers, and airplane owners.  Our attorneys have handled a broad variety of aviation law matters, including personal injury defense; product liability defense litigation; contract and lease drafting; contract negotiation and disputes; and general aviation commercial litigation.

Much of the firm’s practice is devoted to aviation law, and we are one of the few firms in Oregon with aviation trial experience.  Scott Brooksby leads our aviation practice, devoting a substantial amount of his time and practice to aviation-related matters.  Scott served as local counsel for one of the largest aviation manufacturers in the world in a nine-week trial in Oregon state court.  The trial involved product liability issues and concerned a helicopter crash that resulted in burns, permanent injuries, and multiple deaths.  Mr. Brooksby is on the aviation subcommittee of the American Bar Association’s Mass Torts section.  Mr. Brooksby has also been featured as a speaker and a moderator at the American Bar Association’s Aviation Litigation National Institute in New York, New York.

Helicopter Crashes in Helicopter Air Medical Operations

People are surprised to learn that helicopter crashes are more prevalent in Helicopter Air Medical Operations.  Generally, the statistical number of incidents of injury, accident or death in 14 C.F.R.§ 121 (known as “Part 121”, or commercial passenger aviation) operations are incredibly low.  There are more serious injuries and deaths resulting from helicopter air medical operations.

For example, in 2010, according to the NTSB (which is charged with investigating every aviation accident in the United States, and many abroad), there were no fatalities in any of the Part 121 accidents in 2010.  This despite some 17.5 million Part 121 flight hours.  Of all of the Part 121 flight hours in 2010, the most common defining event was a turbulence encounter, accounting for 26% of all Part 121 accidents in 2010.

Most of the defining events for Part 121 accidents in 2010 (just as they have been in general for the last 10 years) were events such as ground collisions, ground handling, runway incursion, cabin safety, system failure, bird strikes etc., many or most of which are ground events.  More than half of the Part 121 accidents that occurred in 2010 occurred during takeoff or landing (according to NTSB data, this is generally true of Part 121 accidents every year).  Less than half of Part 121 accidents in 2010 happened en route.  However, the major factor in Part 121 accidents is turbulence (even though, as a cumulative total, there are more incidents during takeoff and landing than there are en route).  En route, turbulence is the biggest factor in accidents because commercial airlines fly at multiples of the altitude that, for example, helicopters do.

Given the relative flying altitudes, flight durations, weather events, cruise speeds etc., involved in Part 121 operations, turbulence, as it is understood in Part 121 accidents, does not have anything to do with the relatively high incidents involved in helicopter air medical operations or helicopter accidents in general.

Interestingly, according to NTSB data, most helicopter air medical operations involving fatalities do not occur when patients are being transported.  Rather, most occur when helicopters are en route to get patients or when they are transporting organs.  The inference to be drawn is that, while helicopters have great pilots, those pilots are taking chances while flying that they do not take when a patient is on board.

Air medical operations are conducted under both Part 135 and Part 91, depending on whether patients are being carried on board the aircraft.  Helicopter Emergency Medical Services (“HEMS”) missions en route to collect patients, or organs, or to reposition aircraft after accomplishing patient transport operations, are generally conducted under Part 91.  Trips conducted to transport patients or organs on board are conducted under Part 135.  Some air medical helicopter operations, particularly for emergency medical services are conducted by state or local government entities as public use flights, whether patients are on board or not.

Although fixed-wing aircraft are also used for Part 91 and Part 135 medical missions, there were only 10 fixed wing fatalities in air medical operations during the entire decade between 2000 and 2009.

A Statistical Overview of HEMS Accident Frequency and Type

HEMS accounted for about 80 percent of all air medical accidents during the ten-year period 2001-2010.  Against this backdrop, we examine HEMS accidents, where in 2010 alone, there were 13 Helicopter Emergency Medicine Accidents (“HEMS”), 7 of which were fatal.  http://www.ntsb.gov/doclib/reports/2012/ARA1201.pdf (at page 2)  Six of the Seven HEMS fatalities in 2010 involved operations under Part 91.  From 200 through 2010 (the most recent year NTSB statistics are available), 33 percent of HEMS accidents were fatal.  Most HEMS accidents occurred during airborne phases of flight and during 2010, all HEMS fatalities occurred during airborne phases of flight.

Obviously this is explained in part by the fact that unlike fixed-wing air medical operations, HEMS do not generally operate out of establish aerodromes.  Instead, they operate out of off-airport locations where patients are in need of timely, critical care.  In every year except 2007, the number of Part 91 air medical helicopter accidents without patients aboard have been significantly higher than any other category of air medical flying.  http://www.ntsb.gov/doclib/reports/2011/ARA1101.pdf (at page 23)

It may be useful to breakdown the 31 accidents involving 32 helicopters in air medical operations between 2007-2009.  Eighteen were being operated under Part 91, 13 were conducted under Part 135, and one was conducted as a public use flight.  Eleven of the accidents, involving 12 helicopters, were fatal.  Collision with objects on takeoff or landing accounted for 7 of the 31 accidents, but no fatalities.  On the other hand, four of the five controlled flight into terrain accidents were fatal, including the crash of the Maryland State Police Public use flight carrying accident victims on approach to Andrews Air Force Base.  Two of the three loss of control in-flight accidents were fatal, as were two of the three unintended flights into instrument meteorological conditions accidents.  The midair collision between two HEMS helicopters conducting Part 135 operations in Flagstaff, Arizona, in June 2008 was also fatal to all on board.  The other two fatalities involving a non-power plant system were coded as other.  http://www.ntsb.gov/doclib/reports/2011/ARA1101.pdf (at page 24)

What Are The Typical Causes?

In any aviation operation, pilot training and experience, and pilot judgment are some of the most important factors in safe flight.  With helicopter operations generally, and particularly HEMS operations, pilot experience, training and judgment are even more critical because of the conditions they fly in, such as bad weather, night, rural areas where wires or other low strike points may not be lighted or marked and air-traffic may be uncontrolled.  HEMS operations also face an unparalleled need for speed to save lives.  Review of individual NTSB probably cause reports, NTSB factual data and other aviation industry data would tend to suggest that fatal and serious injury helicopter accidents are most often the result of a number of factors including loss of control, visibility issues, wired strikes, system component failure or post-impact fire.  Although some of these issues pose dangers during Part 121 operations, they simply do not pose the same risks, largely due to obvious differences in the nature of the aviation operation, the equipment, altitude, avionics, take-off and landings from tightly controlled air-space and the use of aerodromes.  In addition, HEMS operations often involve situations in which minutes may literally save life and limb, prompting hurried behavior.  While that is not to suggest that HEMS pilots are not some of the best helicopter pilots flying, they do face particular challenges, to which Part 121 pilots or even fixed-wing air medical operations pilots are less exposed.

There are also tremendous swings in helicopter air medical pilot training.  From 2007-2009, for example, NTSB data suggest that the accident helicopter pilots’ median age was 54, ranging from 35 to 69.  Median total flight hours were 7,125 with a range from 2,685 to 18,000.  The median time in the type of accident helicopter was 375 hours, ranging from 11 to 4,241.  Statistics suggest that such variations in flight time and the corollary impact on experience and judgment may be significant factors in the number of crashes. http://www.ntsb.gov/doclib/reports/2011/ARA1101.pdf (at page 26).  HEMS operations more often than not must use unimproved landing sites at accident scenes and helipads and hospitals or medical facilities.  Loss of control in flight was the most common event for both fatal and non-fatal helicopter crashes, followed by collisions on takeoff or landing and system component failure of the power plant.

Even though HEMS pilots may have thousands of flight hours, and are unquestionably some of the best helicopter pilots in the world, owners and operators of HEMS operations should continuously emphasize the consistent causes of HEMS crashes and adapt training programs to focus on those causes.

Olson Brooksby has an active aviation accident and aviation component product liability defense practice.  For more information, please contact our office.