Saturday, August 3, 2019

And Now I Know...

I originally wrote this post for my HEMS (Helicopter Emergency Medical Services) blog, then I sold much of the story to the trade magazine I write for, Vertical 911. Yes, I sold a boat story to a helicopter magazine - as it turns out human factors don't care which mode of transport we are making mistakes on. I share it here in the hope that you get something out of it and perhaps avoid disappointment. If you routinely boat with other members of your family or friends, share this with them and discuss when it's a good idea for them to "speak up."

Safe Boating friends,

Dan Foulds

...A year and a half back, I ceased to be a HEMS pilot. I had 30 years of flying behind me and got tired of traveling so much for work. It seemed like a good time to experience some more of life's adventures.

I still travel in order to present Air Medical Resource Management Training and am lucky enough to spend time with my heroes - the men and women who fly and crew EMS helicopters all across the United States. I am amazed at the speed with which a bond of affection can be established with a flight team; maybe it's mutual respect and admiration, maybe they appreciate that I am trying to prevent the next crash. Funny thing is, life is busier now that it was before; Writing here on the blog, and for Vertical 911 keeps me busy. And then there's the boat.

My life has centered around water and sky since I was very young. After giving up my wings I attended Sea School and obtained a 50-ton master's credential. And I got a part-time job as a mate on a tour boat. Working on the boat is pure pleasure. No one is hurt or sick, and people are there to have fun. I earn beer money and meet people from all over. And I learn lessons.

If you want to see what a dolphin boat tour looks like, check out this video. Buddy is pulling up a trawl that we have been dragging off the bow. In a few seconds, he will toss a small crab onto a child and screams will hit a pitch above human hearing...



So far I have had two sentinel learning events. I can relate both directly to HEMS. Both of these events involve situational awareness, something we talk about in any AMRM training class. SA is a team imperative.

In the days after Hurricane Matthew walloped coastal Georgia, trees, docks, and sunken boats were drifting around in our tidal creeks and rivers. One morning Captain Buddy and I took a group out for a tour. As is our custom, he worked the front of the boat, presenting his description of the coastal environment, and I was at the helm at the rear. I turned to port to enter the Skidaway River, and across the channel, perhaps a quarter-mile to starboard I observed an irregularity in the flow of the outgoing tide. There was something affecting the surface of the water over there, but it was too far away to determine what it might be.

This was a level 1 situational awareness situation - I had perceived something with one of my senses; sight.

We proceeded south along the nearshore for a mile or so looking for the dolphins who live and feed in that area. After not seeing any, Captain Buddy suggested we do a 180 and cross the river to the far side. So I drove us the distance to the far shore and headed back the way we had come.

When I am driving the boat, I keep in mind that I have people's children on board, and I am responsible for their well-being - in the same way that I used to be responsible for my crews and patients. So I am cordial with the guests, but I keep my eyes and ears open, looking for trouble. We are only running about 9 knots, so I usually have plenty of time to see and react to a hazard.

But on this morning, a parent stood next to me at the helm, asking questions about my job and history. Captain Buddy was 30 feet in front of me, talking about Spartina Alternaflora to the kids. I swung my head left and right and in the swing saw him wave his arms at me excitedly. And he was yelling...

I felt a series of mild thumps in the soles of my shoes and snatched both throttles into hard reverse. And I held the motor trim switches in the "up" position. As the props on the twin Yamahas came out of the water I switched off both keys, hands shaking.

And then the entire walkway portion of someone's dock drifted out from under our boat.

Damn. That was close.

We shook off the adrenaline, made sure that everyone was okay, and got underway again. When we got back to the dock and discharged our group, Buddy and I did a debrief. I had to confess my error to him so that we both might learn from my mistake. You see, I saw that disturbance in the water flow several minutes before I encountered the object that was creating it. And I should have SOUNDED THE ALARM. We sound the alarm when we become aware that something is different so that everyone on board is aware of the phenomenon. We verbalize our perception. We take our SA to the second level - "hey I sense this or that and I think it is important for us to be aware of it." The majority of the time when something goes wrong in HEMS, some person has an inkling that something is amiss. But they don't sound the alarm.

By speaking up, we increase the chance that someone will take SA to the third level - projection. We want to be aware of our circumstances and constantly project what the future might hold, based on what we know now. But because I didn't sound the alarm, and forgot about what I had sensed before, we didn't get past my level 1 SA. It could have been much worse.  We both learned something that day. And I logged my mistake - something I suggest you do too. Keep a log of your mistakes and review them periodically.

Then there was that time we crashed...

Years ago, a friend of mine, Flight Nurse Donnie Thompson, was a member of a crew who flew a patient from Atlanta to Greenville, South Carolina. They flew their patient, went to the Greenville Airport for fuel and cookies and lemonade, and headed out to the aircraft for the flight home. It was a pretty day, and spirits were high. As they rode along one of the two crew members in the cabin remarked, "HEY, the key isn't on the hook!" The key being referred to was the key for the fuel cap. It would normally be used during refueling, then put back in place after fueling was complete and the cap was secured.

The pilot became quiet. He wasn't saying much, but his brain was twirling. "Did I leave the fuel cap off? Is it laying on the asphalt back at the airport? Will we get back without a fuel cap? Will I get in trouble? Will I get fired?"

Without saying anything about all this, he announced, "guys, there is a big field in front of us. I am going to land and check the fuel cap."

Now when I am presenting this case in class, this is where I say something like "you people who have been flying for a while know that there is a normal sequence of events to a flight and a landing. When we are preparing to land, we do an orbit at altitude. We verbalize the high recon, the before landing check, and announce where we think the winds are from. We talk about obstacles on the way in during the low recon.

The approach is conducted "at the apparent rate of closure of a brisk walk," and if you work for Air Methods you descend through the last 300 feet at 200 feet per minute. I ask the people in the room to be aware of what is happening on approaches and to call for a go-around if things seem out of order. "Hey, you are smart people! Don't let me crash you because I am distracted or upset!"

That fine day, that good and experienced pilot fell prey to human factors and flew that perfectly good helicopter straight into that field, too fast, and destroyed it. Luckily no one was killed. And of course, I would never do something like that. Nor would I let another pilot do that to me. Right?

Human nature can hurt us. When one of your passenger's hats blows off at speed,
what is your immediate response? A hard turn to recover it before it sinks? That action once resulted in a fatality. I have done it twice in the last month and I know better!. A much safer response after a hat blows off? Announce "Slowing down guys!" Then reduce speed and return to the lost object in the water. If it's gone, so be it. Don't lose a head over a hat.


So, after having discussed this event, maybe a hundred times over the last five or six years, you would think I would know enough to speak up if someone was about to crash with me on board. But it's harder than I imagined to know what to say and when to say it. A couple of months ago, we were taking a group of tourists back to the Landings Harbor Marina. This marina is enclosed with a metal seawall, and tight. It's hard to maneuver our 45-foot boat in the enclosure, and Buddy does this task himself. I should mention here that docking a boat is different than landing a helicopter. The tried and true technique for landing is to approach slowly, carefully, cautiously. But boat captains will occasionally be forced by wind and current to make a fast approach, then use bursts of power to arrest forward motion and swing the stern towards the dock. When I first saw Buddy doing this it made me nervous, and glad that it wasn't me doing it. But I have watched him do it for several months, and I never saw him make a mistake. Every time, he would use skill and power to put the boat right up to the dock, So on that evening in the tight little docking basin, as I stood on the front platform and watched us rapidly approach the dock I wasn't worried. Buddy is a great and experienced Captain, and he is my teacher.

Closer. Still fast
.
I looked back down the length of the boat. He was looking intently at where we were headed - toward a fuel dock at a 45-degree angle. We had 7 or 8 knots of speed through the water, on a big heavy boat. I looked back to the front.

Really close now.

We aren't going to stop! As we slammed our bow into the dock I stepped off of the bow platform. Buddy yelled, "DAN, why didn't you say something?

We unloaded our slightly ruffled passengers and did a debrief right there. And I explained why I didn't speak up. I thought of Donnie Thompson and the Rescue Air One helicopter that was destroyed by a distracted pilot. Now I know, it's harder than I imagined it might be, while I stood there in class and asked crews to monitor the pilot's actions and speak up if something is wrong. Maybe you don't know exactly when the pilot is making a mistake. So how will we learn about this? How are we going to know what is okay and what isn't? How are we going to know what to say, and when to say it?

The answer is education, and communication, and consideration. Humility and respect will help, as will honest discussions of past mistakes. After all, we can learn from other people's mistakes, or we can repeat them ourselves...


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