Scud Running Pilot Gets Himself, Physician, and Nurse Killed | The Story of Medflight N135UW (39)

[@TheDrMedic]

I probably could have clarified this better in the video so that is my mistake. At the time, the GPS satellite tracking identified a position roughly every 3 minutes. The GPS satellite tracking DID give their location when they first took off from LSE, but the airport was their last known location. Given that they only flew about 4.5 miles, it is likely that the next GPS tracking just didn't occur yet and that their entire flight only lasted just about 3 minutes. While this was a terrible tragedy, many lessons were learned from this accident and many others in 2008. These lessons have made the HEMS industry much safer today. But, we could probably still do better, right? Fly safe, everyone...

[@melissajohnson2935]

Would love a video 9n Pafford Air One crash that happened in Arkansas in 2017. Thanks for these videos!

[@amberoduane1648]

Another that I would like you to go over is the fatal 2016 Cal-Ore fixed wing crash

[@TellTheTruth1]

@@amberoduane1648 I doubt any of these West Coast aviation ‘s, KZbin channels would do a comprehensive video on the crash of N661 TC because most of the aircraft communitie are go old boys and don’t want to offend their networking and buddies

[@avocadoflight]

Thanks @TheDrMedic appreciate all the content!

[@pantherplatform]

*PLEASE PLEASE PLEASE* do a video of the medical helicopter that crashed in Hazelhurst, Wi on April 26, 2018.

[@mike-cl1mm]

I was the pilot that just left UW prior to that accident , a terribly sad time one pilot called me when he showed up for the morning shift. He was so upset , he just kept saying “ they never came back” I think you did a good job of presenting information. I am retired pilot for a long time now , I feel blessed to have “ made it back” every time and pray for all pilots and crews we try to learn and improve safety when we evaluate past flight good and bad we always try to learn and improve.

[@Hug_life]

How long did you fly for? My Dad was the lead physician from 1995-2000

[@Hug_life]

I just shared my favorite story from my Dad in the comments. If you were the pilot from my story then hi! & thank you!!

[@maxasaurus3008]

Thank you for all the lives you saved

[@yempab]

As an emergency physician and transport safety specialist, I was taught long ago to say "crash" rather than "accident," the point being that all of these incidents had foreseeable problems that, if heeded, would have prevented them. Implicit in the term "accident" is the notion of unpredictability and inevitability. The goal of your excellent series, a goal which I think you accomplish admirably, is to use specific incidents as teaching moments which can prevent future mayhem. Or, as we say in the prevention world, "A crash is no accident." Thanks for your work. Your production values are superb.

[@justinhaase8825]

My local Highway Patrol uses crash reports instead of accident reports.

[@markwilliams2620]

CFIT. That's it.

[@wojciechgrodnicki6302]

Accident implies there’s no one at fault. Thank you Sgt. Angel.

[@tallen6641]

Language matters. Agree completely. Example: I adopted my son. How I refer to him as just my son, not my adopted son, matters to him. And I should get the label for doing this, not him. In the firearms community, many discourage the term “accidental discharge” in favor of “negligent discharge.” In all these examples we’re just assigning responsibility to the person doing the action. Seems simple enough.

[@Golgi-Gyges]

A crash is still an unintended accident. (I was around when this terminology was mandated to the news media by the government...cay you say overreach?)

[@edwardscott3262]

I blame the FAA. This type of thing seems like a common occurrence. A pilot fully capable of IFR flight, in an IFR capable aircraft crashing while struggling to stay within VFR limits. No pilot should have to choose the more dangerous option just so they don't risk their license. There needs to be a system to allow IFR capable but not current pilots to go IFR without regulatory risk. Maybe have them declare an emergency. Maybe when it happens give them 6 months to get IFR current. Any system that makes pilots fear the FAA more than they fear crashing is a really broken system and needs to be fixed.

[@TheRunAndGun10]

Best summary I’ve read so far and spot on n my opinion. The “rules” killed these folks this time as opposed to not following the rules.

[@Arturo-lapaz]

Wrong, this was a decision of the pilot to fly in IMC, knowing full well that he was not current flying solely by reference to the flight instruments, IFR or VFR, R denotes rules, not conditions! CFII here, taking instrument flight training seriously. The FAA is already meddling too much. FAA employees in the majority do not hold Certificates, just interpret FAR's litterally. Don't make their involvement more bureaucratic. PLEASE. passing a six month currency test does not mean the capability nor the judgement to fly in IMC, just proving ability to fly instrument aprroaches, read the FAR's.

[@Moser72]

A lot has changed since 2008. Long story short, industry wide, we are taught that if you get caught in deteriorating weather and have to commit to instrument flight, do it and declare an emergency. Generally speaking, you will not get in trouble for this. Yet people are still afraid.

[@mikeoneill3205]

As an ER doctor you would not believe how many flights are not necessary, everyone wants to "Launch the bird".

[@HRCISASKNK]

Absolutely. Been EMS pilot for 18 years and 80% of the time it’s a taxi ride. When someone asks what I do my response is “I’m an Uber driver.” It’s all about flight volume and $$$$$$. If people knew the inherent risks, especially at night, associated with this industry they would not take “taxi” rides in it.

[@n3roc]

Also, only the exceedingly rich can even afford the insurance copay of a 20 mile chopper ride.

[@paulhendershott667]

You bet! Pilots are looking for any excuse to fly, can't blame them, flyers gotta fly! 😅 I'm sure it's a rush for the crew

[@archieletsyouknow5508]

💯🤔 I've heard some horror stories of people being evacuated from Mountain and cannot pay the evacuation and ruin their lives take their house take their saving😮

[@ChungusTheLarge]

But it go fadoo fadoo fadoo fadoo and no car in the way

[@Delatta1961]

Great presentation. As a retired HEMS Pilot of EC-135s, everything technical was spot on.

[@DirtyBob2001]

I used to do a lot of scud running with an air crane operatorations company in S-61s twenty years ago. I have quite a few memorable experiences of trying to get to the next job in bad weather looking for a path through the mountains. Sometimes it was fun, other times you'd just have to ask yourself why are we doing this. I always liked how cows would stand there calmly and track the low flying helicopter passing by, moving their heads in unison chewing their cud.

[@drobichaud1000]

Ok nice try capt air crane

[@DirtyBob2001]

@@drobichaud1000 I prefer CPT Sea King. I would also accept CPT Long Line.

[@jamesps7515]

@@drobichaud1000you’re an idiot. Sounds like you wish you had any experience at all.

[@fxsrider]

Straight out of a Southpark episode if I was writing one.

[@samanthahunter4176]

I am an AEMT in rural NY. I have heard from multiple flight crews that HEMS is years behind in the aviation world, which is so unfortunate for flight crews and pts

[@travelwithtony5767]

They have multiple million dollar helicopters which cost $30K an hour to operate, which certainly helps to explain why healthcare in America is so ridiculously expensive. Half the time they aren’t even needed, but they are deployed instead of ambulances to pad the profits of the hospitals that own them. *Don’t ask me how I know, just take my word for it.

[@Jonathan906]

That was my first thought when I read it was a hospital-to-hospital transfer. Prairie du Chien to LaCrosse is about an hour's drive according to Google Maps. Did calling in a helicopter from Madison really save any time over a much less expensive ambulance transfer?

[@travelwithtony5767]

@@Jonathan906 Exactly, makes no sense..also when you factor in time it takes to mobilize personnel, checking the weather, filing a flight plan and then finding a suitable place to land which can often be a km or more from the accident site, the time savings is negligible..also most helicopters are smaller than ambulances which means they aren’t as well equipped either..not saying they are never needed and admit they have saved thousands of lives, but I don’t think they are needed half the time..would be interesting to see the stats but I’m sure they’re buried and hidden from public scrutiny.

[@r2db]

You clearly know nothing about this specific program. The costs (both lift-off and mileage) were significantly less than other helicopter EMS programs in the state and it is the only program that always had emergency physicians on the crew. Some of the facilities that commonly called this program did not have emergency physicians staffing their hospital ED and were often incapable of routine medical and trauma resuscitation, skills that the program made sure their flight crews had. It was not uncommon for the flight crew to do in a few minutes some stabilizing treatment that would have taken over an hour for the sending facility to call in staff from home and perform. Furthermore, ground transportation from some of the rural Wisconsin hospitals to a facility capable of caring for the patient would often take many hours (frequently 6-8 hours) to find an available ambulance and transport the patient, versus a 30-40 minute flight. Yes, patients were often flown because ambulances were not available. Neither of us has the ability to magically put staffed critical care ambulances everywhere. Finally, if you have seen critical care ambulance bills from for-profit companies the bills from a government-run program as this one start to look very reasonable. If you think that a helicopter that costs a few million dollars and gets used at any hour, day or night, weekends or holidays, is excessive and wasteful then maybe you should look into how much an MRI machine costs. Those often are only used during bankers hours on weekdays, and maybe a few hours on Saturdays.

[@crazyralph6386]

$30K per hour??? 😂

[@LatitudeSky]

The EC135 runs about $1500 an hour. I think that's low. Probably closer to 2500 an hour. But either way, it's not at all 30 grand an hour.

[@joeh4295]

As a miltary medic veteran and now a civilian paramedic, HEMS some of the safest pilots Ive ever known with many of them being military helicopter pilot veterans. After 33 years in EMS the EC 145 is the most advanced and best HEMS helciopter Ive ever seen.

[@fw1421]

Back in 1985 I was in Winston Salem,NC for a training class at the Hospital. I watched a Medevac helicopter take off from the ER helipad. Unknown to us in the class on the way back to the hospital the copter would fly into a mountain top. I found out about the accident on my way back home in Raleigh on the radio. Very sad situation.

[@deborahchesser7375]

That would almost make you reconsider career choices

[@MotJ949]

I remember this night, I lived a few miles from the airport UW FFL flew out of. We all pretended that there was hope they would be found but we all knew they’d flown into the bluffs.

[@toctuning]

Was on McCormick ave just off hwy 30 (before the reconstruction it connected) and recall this happening. A few months later I almost needed it myself in a motorcycle wreck. Wild seeing stuff like this on youtube knowing it was local.

[@toctuning]

Also just to ad it in, UW, Meriter, and Sauk Medical have all been incredible in keeping me alive through my extreme sports lifestyle back in the 90's and early 2000's. God bless the ones willing to run towards danger and keep a calm head when saving lives.

[@NotSoCrazyNinja]

Well, technically trees took them down. The bluffs were a contributing factor (putting the trees high enough for them to hit). Never give up hope though in such situations because I have seen some situations you would almost be sure nobody survived, but people survived somehow. They're not deceased until proven to be so.

[@autoteleology]

@@NotSoCrazyNinjaSee also: Japan Air Lines Flight 123, so many preventable deaths from negligently assuming all lives were inevitably lost

[@patrickmontie9583]

Yeah, helicopter medicine seems cool at first. I spent 25 years in EMS and called for helicopters 4 or 5 times. Weather always canceled the Helicopter. I just referred to them as fair weather EMS. 😊

[@cmiller8006]

Thats a pretty shitty comment. Guess you have no knowledge of aviation.

[@paddy1952]

In the 1980s I flew med-evacs in Northern Saskatchewan, Northern Manitoba, and later, all over Ontario. After scaring the beejeeziz out of myself by pushing weather on one of my first few med-evacs, I came up with the policy that I wouldn't fly a med-evac in any conditions that I wouldn't fly a routine transfer in. In twenty years nobody died.

[@Kishanth.J]

Did you fly for Ornge?

[@paddy1952]

@@Kishanth.J There was no Orange. It was the shortcomings of the old system that Orange was designed to address. In the late 1980's I was Chief Pilot for Samaritan Air Ambulance at Buttonville.

[@alanclark639]

As an avid rotor buff here in the U.K. I'd say your channel deserves more views and subscribers - you investigate fairly bringing out all the available information. It's a sad fact that there are far to many questionable occurrences in helicopter operations and particularly in medical flights. On first impression from this side of the pond it looks though the U.S. system is rather flawed with some companies being willing to employ just about anyone that wants to jump in the driver's seat or browbeat regular guys to fly when others won't - but that would be unfair as here in the U.K. we've had beyond our share of envelope pushers. Time was, you could rely on an Air Investigation - everybody worked to find the genuine reason for the sake of preventing a further occurrence - but these days - it's just arse covering and vested interests.

[@tommyanderson-filmmaker3976]

I was surprised to see you video pop into my feed. That is because these were my friends and I was one of the Madison Fire Department Fire Medics who helped set up the original Med-Flight system at University Hospital in 1985. The head of the Med-Flight program then was the wife of one of our fire-medics and many of us firefighters worked in the ER and CICU part-time. In fact my daughter was working in the UW ER when they had lost contact and she called me from the ER, being a former army helicopter crewmember my first thought was the La Crosse Coulees especially with the weather changing. I had thought at the time the pilot was trying to clear the coulees and weather before IFR flight rules kicked in.

[@emullen93]

Currently just started flying for a dual pilot, IFR capable hospital based program who partners with a big part-135. I don’t feel pressured to fly in bad weather AT ALL. It is a very safety conscious and safety focused environment. I can’t complain

[@heloaviator229]

I am a retired helicopter pilot who only did utility work (Firefighting, logging, construction) never any EMS. That being said, in our operations we always thought that the multiple mishaps of EMS drove OVER regulation of the entire industry. I truly believe EMS who operate at night or IFR should be mandated to fly with two qualified pilots. For you current or retired EMS pilots, what do you think about a 2 pilots requirement and the effect on safety?

[@Moser72]

While a lot has changed since 2008, (HTAWS, various weather min regs, use of NVG’s etc) a single pilot IFR equipped helicopter really doesn’t get much safer with a second pilot. The trade off in fuel, payload, performance isn’t worth it. This helicopter’s automation capability makes it really simple to fly IFR. I did SPIFR for 5 years in the 135 and 145 and never once would have appreciated an unnecessary 200+ pound self loading baggage meat servo next to me. Ha ha. Really what needs to happen to prevent CFIT or IIMC crashes is having the industry commit to IFR operations. If this pilot was operating or able to operate IFR, he’d have been fine. You’re always going to encounter situations where you cannot fly IFR though. 1) Pilot is not current or qualified on the certificate yet. That’s actually normal during the first several months at an IFR base in many programs. I think it’s a poor industry practice that needs to stop. My former employer practiced it, because they thought it was safer to not burden a pilot with IFR operational concerns when they are new to the program/aircraft/region etc. That’s illogical. If it takes an extra couple weeks to get that pilot started, take it. What we did was first 6 months VFR. Then at 6 months we went to the SPIFR course and got qualified and did a 135.297 IFR checkride. For the next 6months we dabbled with IFR operations so long as the current or forecast weather was supposed to be 700’ ceilings and 2 miles visibility. Personally, I found this restriction to be a burden. The only restriction I would say is valid is not to push the minimums for visibility on an IFR departure and approach. 500/1 is actually fairly useful we’d graduate to that after our first 6 months of being IFR qual’d. Every operator is different. Anyway, all this being said, you could have an MEL’d item that prevents IFR flight and then be stuck with VFR restrictions. The key is to not pressure a pilot to fly and to reward good decisions and implement reasonable buffers in the FAA weather minimums when operating VFR. The FAA minimums are honestly not safe under most circumstances. No matter what though, you could simply find yourself in conditions that were not forecast despite vigilant planning, as you’re aware. Ha ha. The key for these pilots is to be drilled and indoctrinated with an enroute decision point mentality. Ceilings reported or forecast to be 2000’ but are 1500 and now you’re having trouble maintaining your MSA for the numerous obstructions along your route? Turn around. Visibility has you slowing from 120 to 90 knots? Turn around. Not safe to turn around because things went bad too quick? Autopilot upper modes set as desired, climb initiated to a safe altitude, call ATC and declare an emergency. It’s gonna suck if you’re not competent in the aircraft’s navigation and auto flight systems, but there’s no excuse for that. I think the FAA has signal’s that they want to move all operations to be IFR capable. Over the years we’ve seen them mandate radar altimeters, IFR certs, HTAWS, operational control centers to aid in decision making and flight monitoring, flight data recorders, etc. I believe the next regs will likely be autopilots installed in VFR aircraft. Both operators I’ve worked for have done this on their own. The FAA has relaxed its requirements for single engine IFR certification though, signalling that they recognize the need for the expense of a traditional IFR helicopter to be eliminated from the calculus of whether to do IFR operations or not. Right now you can buy 407’s and AW119’s that are IFR certified and more are coming. Eventually the FAA will drop the hammer and mandate HAA, formerly known as HEMS, to be IFR capable and current. The training and currency requirements don’t really need to be cost prohibitive. Let’s say you’ve got a new model H145 or larger aircraft that could handle the weight of an extra pilot and still have a useful load and perform for IFR operations…. Sure, you could arguable be safer, but most likely that isn’t going to be realized outside of a pilot incapacitation event. The newest aircraft that have a useful load capable of operating two pilots are coming out with 4 axis autopilots and capabilities that can even manage that situation so long as med crew are trained to press a few buttons.

[@samuraiwarriorsunite]

Speaking for myself, If I was facing death, the last thing on my mind would be to worry about how many piercings, tattoos, or earrings the person trying to save my life has.

[@57Jimmy]

Exactly! Because each and every one of them will give it 150% with the same dedication as the elite special forces of our Armed Forces and Police!💕

[@NaughtyAelf]

Ah damn, I used to work at uw. I knew these wonderful people. That was a painful time. 💔

[@joeh4295]

So sorry for the loss. Ive been in EMS for 33 years and lost HEMS friends too. It's always painful even if you don't them.

[@wayneblubaugh2122]

As an 18 year full time paramedic (certified 29 years), I was never a designated medical helicopter crew member, but when needed, I did fly with the several hospital based services on multiple occasions. It is my opinion that at least 85% of these flight transports could have been handled safer using ground transport, with no detriment to the patient as to time delay. I'm sorry to say that we used to make the joke that so-called "live flights" were really "dash-for-cash flights." In this case, controlled flight into terrain cannot be written off as "fog" or a "bent pin." This is a combination of pilot error and inadequate oversight of the necessity for IFR certification. I understand that there is now a memorial for medical flight crew members with the names of over 350 personnel who have died in these crashes (not counting patients who perished). It's an outrage.

[@Ryanboy2020]

Excellent recap and analysis!! We were given this example in my Flight Medic training as a watershed moment in the HEMS world. Two thoughts if I may. First, I cannot understand at all why none of the medical personnel on board would sit shotgun with the pilot to help in observation of the flight. At CalStar, the company I work for, we are always encouraged to sit up front during runs when we do not have a patient and our pilots welcome the extra set of eyes. Second, I find it difficult to understand why the medical crew would not choose to wear their helmets? We are required to wear them and the company spends a lot of money purchasing the best aviation helmet/comms systems available. You are in a aircraft subject to the laws of gravity and its effects at any time during flight. Even a "rough" landing can knock you around the cabin even when your in your seat and restrained. Why not give yourself that extra layer of protection?

[@nicolad8822]

And how can they even communicate with each other without helmets?

[@drobichaud1000]

Harley riders don't wear helmets either - its like their culture I guess - maybe these personnel didn't want to be called sissies by wearing helmets like a harley rider.

[@Ryanboy2020]

@@drobichaud1000 We have a safety culture in aviation that is foremost in everything we do. To compare someone who rides a motorcycle and doesnt want to wear a helmet (as stupid as that is) to pilots or members of the aviation community is irresponsible. There is no safety culture in riding a motorcycle. The flight medical crew in this accident most likely didnt feel the immediate threat or need to wear a helmet. Its not like wearing a motorcycle style helmet. The aviation helmets are remarkably comfortable and well made with communication equipment built in. There is no good reason why they shouldn't have been wearing a helmet other then to say we have learned a lot since this accident and you will not find a air crew member on HEMS operating today that doesn't wear a flight crew helmet.

[@drobichaud1000]

@@Ryanboy2020 your right - I made a stupid remark so as to stick it to motorcycles

[@csolivais1979]

​@@drobichaud1000what did motorcycles ever do to you?

[@j.w.perkins6004]

As a fixed-wing air ambulance pilot in Central America that is fully instrument rated, I was terrified not by bad weather but the scud running locals (including local airlines) who were not instrument rated but routinely flew in 300' overcast weather. We had loran with our own appraches. I was always afraid of popping out of an overcast only to have a mid-air with one of these idiots!

[@TheDrMedic]

OMG I cannot imagine scud running local airlines in that area!

[@MGJDMNJ]

It’s awkward to say I’m excited when you upload a new vid as it is usually related to a tragedy. However, your respectful handling and explanation of these incidents allows them to be viewed as they should be: teachable moments. Amazing video as always

[@nwanchorcertification]

I look forward to the content it just sad that it’s necessary

[@jimmydulin928]

I very much agree with your last statement that two pilots would have made a big difference. I flew UH1-H Hueys in the NMARNG as medevac before night vision goggles and the terrain instruments. As we had no autopilot, fatigue induced vertigo was and issue, but sharing stick time, especially IMC, made it a non-issue. The doctor or nurse up front should help them, but two pilots is more than twice as safe. The single pilot non-instrument scud run problem is that visibility and therefor safety get better the lower we get and going IMC, even for the instrument, it is the transition that will kill us. I backhauled the two pilots of a C-130 crash at Brave Shield 79 to Loma Linda Burn Unit in LA. The one with helmet had burns but was in fair shape. The one who wore headset instead of SPH-4 helmet had his eyes closed by the top of his skull crushed down. I know computers are very helpful, but I cannot understand highers putting so much money into equipment but so little into hiring two pilots. All the computers in the world, save fully drone operations, will be worth that other pilot.

[@metallicaone4052]

Great analogy and description of the accident. You also do a great job of showing respect to all parties involved. Definitely a sad situation.

[@twainnorton6035]

This is the second time I have been able to watch your video and find it amazing and filled with everything anyone, whether a professional or not wants to come back for the next video! You are something else in your ability cover all that is necessary to have an understanding to get it from a young individual to the most professional pilot. Kudos to you…see you in the next one.

[@TheDrMedic]

Wow, thank you!

[@carolfrazer8067]

I remember that crash. Unless you live around theses bluffs, you have no idea how fast fog can move in. It was super foggy that night.

[@Tripplebeem]

I live an hour south of Madison and these UW Health helicopters fly over my house on a daily basis as they serve several hospitals within a couple of miles from me. I had never heard about this accident, thank you for this information.

[@EchoKilo]

The pilot should have gone wings level, initiated a climb and declared an emergency. The fear of admitting a mistake to ATC and Air Methods was too great.

[@spikenomoon]

Make a mistake these days is a career killer. At the minimum all people who fly regularly with these pilots should be interviewed and their opinions taking into account to determine what discipline should be taken?? I’ve heard a couple of these where the character of the pilot was suspect. If this is the case they should be gone before they destroy others lives.

[@LoisoPondohva]

​@@spikenomoon eh, death is a more sure career killer.

[@handynothandsome261]

Extraordinarily thorough and intelligent overview of this crash. Thank you. This hits close to home, as the company I worked for, Intermountain Healthcare, in a couple of crashes over a short time frame, lost a couple of crews and also a patient- when that ship got lost in a squall and crashed into a mountain. The outcome eventually was that they replaced their fleet with four (at the time- now eight, I believe) new Augusta Grande helicopters (one with a hoist)- all equipped with IFR, Doppler weather radar, and forward-looking radar, with significantly-increased service ceiling and payload capacity (so no more frantic Moms left to drive to the new hospital as they watch their baby fly away in the LifeFlight helicopter)… Since then (knock wood) I hear LifeFlight and AirMed choppers buzzing up and down the valley almost daily- the Augusta Grande, with it’s four-bladed rotor, makes a very distinctive sound, so I know who it is without even seeing them.

[@JeepCherokeeful]

There are hills and bluffs all over the area between La crosse/Madison, who would think they can fly vfr into clouds/fog at night?

[@lyfandeth]

About two weeks ago, Broward Sheriff's Office helo crashed minutes after takeoff. Apparent gross mechanical failure compounded by the pilot trying to return to base, a critical few minutes. One crew killed, one ground killed. They had been dispatched to an auto accident and when an ambulance took both auto victims to the hospital, they were reported to have "non life threatening injuries". Two dead, three injured, one chopper destroyed, all for an unnecessary trip.

[@progshark]

Airmethods having their NASDAQ symbol prominently displayed on the letterhead used for the investigation report tells me exactly where their priorities are.

[@jmax8692]

A logo is a logo.. you’re no detective

[@t.o.4876]

Thank you for covering this flight. I stumbled across your videos about a year ago and searched them for this flight, but you hadn’t done it yet. Fast forward to a few weeks ago and I was delighted to see this video come across my KZbin feed. At the time of this crash I was a volunteer EMT/firefighter in the Madison area. Mark Coyne was my EMS instructor in my EMT-B class in early 2005. He always gave me a difficult time because he knew my father, as my father was also a medic in the area for several years. He genuinely help guide my future in medicine, as I am now a nurse in Texas working my way towards my FNP. When I started the course I thought it was necessary evil within the fire service. By the time I completed that course I was in love with the medical field and was full of confidence to make a difference. He was an intelligent and fun teacher, with many “markisms” that I can still hear in my head. I can vividly remember checking my email at work that morning (I worked as a medical assistant at UW hospital) and they had mailed all staff with the news. It was a tremendous tragedy for the community, particularly because of mark and Dr. Bean’s impact on the emergency medical services in the region. I still get goosebumps thinking about the missing man formation they did at their funerals. Thank you for shedding light in the accident and doing it with dignity for those that were lost.

[@maxasaurus3008]

Thank you to all the Emergency Personnel out there, I owe my life to a ski patrol and a few ambulance crews out there not to mention doctors. Thank You all ❤❤.

[@JustMe00257]

Commercial VFR ops are inherently challenging. They tend to put a lot of pressure on the pilots to make a decision to go or not when conditions become questionable.

[@HG-Studio]

Great video and an accident I have personal knowledge of as I knew the flight doc and knew even better Mark the RN. I don't know if it would or should have made any difference and wonder if it was not noted in the documents, but Coyne himself was a licensed fixed wing pilot with instrument rating. He may have held commercial privileges as well though I'm not sure of that. I flew with him a couple times in his Cherokee 6. I've always wondered if he was aware of what was going on in the front, and if he tried to intervene at all? Certainly he may have known the dangers of what they were doing being a pilot himself. I'm sure you can verify his pilot status and would have been at least an interesting addition to your story.

[@MrJones-uq5cg]

I worked with Mark at UW as well. Not a lot, but enough to know he was a great guy. Always cheerful and funny. He used to tell stories about flying his Cherokee to the Bahamas...Or was it Bermuda? 20+ years ago.

[@joeduc621]

Mark was my friend and neighbor at our residential airpark near Madison, WI. He was as dedicated to recreational flying (Piper Comanche) as he was to his profession and treated everything he did with that same level of dedication. He was also a licensed sea Captain and regularly sailed the Caribbean. His wonderful wife was a nurse at UW Health, like Mark. The two of them embodied the concept of "giving back." We all lost a good man that day.

[@krautyvonlederhosen]

@@MrJones-uq5cg likely it was the Bahamas as Bermuda would have been a stretch for a Cherokee .

[@robertbandusky9565]

Sounds like Koby Briant accident! Inexcusable in a flying machine that can reduce speed to zero and land or make 180 degree and return on safe inbound course😎

[@UQRXD]

To fast to low. I am amazed at the cheap switch they used. Not that it had any thing to do with the crash. They gave their lives so in the future others can be saved. I am surprised how many times medical rescue helicopters have crashed, having done search and rescue myself.

[@srcastic8764]

Even if I were not current for IFR, but was still IFR trained, if weather moved in and it was too dangerous to move VFR I would have gone to IFR, current or not, just to get home. Better to risk a violation than risk lives.

[@keithbrunson7190]

Just an outstanding summation of the events that went poorly. Excellent work.

[@Cody27]

I was in a bad car wreck once. I dont remember but a helicopter landed on the highway and flew me to a hospital. Apparently I was talking to some of the crew about video games. less than a month later they crashed somewhere in NW Arkansas and all died. I never got to say thanks.

[@Maggie-tr2kd]

Excellent video, clearly explained despite differing report results. I am commenting to note a different issue. At about 32:39 or 32:40 you can see a pilot of a helicopter shown on your video with what looks like a computer tablet on his lap. Please note that there was a recent fatal accident in a firefighter CH-47D helicopter caused by a iPad tablet that got loose in the cockpit, fell down into the controls, jammed something, which the pilot could not reach, causing a crash and two fatalities. Blancolirio has the video about it on his channel. Something to think about.

[@TheDrMedic]

That is an excellent observation. The CH47 accident was certainly a tragedy. In the video you see here though, she has the iPad strapped around her leg which shouldn't be a problem. I have seen pilots just rest the tablet on their leg which is definitely a tragedy waiting to happen.

[@Maggie-tr2kd]

@@TheDrMedic Thank you, my oversight. I will take a look at it again. I failed to notice the iPad was actually strapped around the pilot's leg. Great awareness on the part of the pilot.

[@ryanarellanes8009]

I watched Blancolirio's analysis of the iPad Chinook incident. Must have been terrifying for the crew. Dropping your iPad, jamming up the foot controls, and not being able to do a thing about it while plummeting 250 ft into the river.

[@keithbrunson7190]

Flying a helicopter is an entirely different world than flying fixed wing. It is so much more complicated. And so many things can go wrong.

[@didamnesia3575]

​@@TheDrMedicnope. That iPad is Not strapped down. You're seeing the backside of the case underneath but on top of pilots knee. When pilot touchs iPad it jostled quite a bit. If I'm a customer and see that, after landing the pilot is going to be taken out back for a bit. Yall pilots need to stop fkn around

[@tallen6641]

I devour air investigation video but never saw yours until this episode. My loss for sure. You finished with a comment about 2 pilots making a difference. I’ve heard that same issue of the single pilot in rescue aircraft raised on the Blancolirio channel. If not this U Wisconsin program with seemingly unlimited will to spend, then who will ever go for that? It makes me really question the whole business. I should note that I was on an accident flight, DC-9 about 25 years ago and still manage the PTSD. So obvious ignored problems really get under my skin. I look forward to more of these episodes.

[@Absaalookemensch]

Prayers to the family and loved ones of the crew. This hits home as I flew critical care air transport for years.

[@brianford8493]

The thoroughness of the investigators at such events just blows my teeny brain.

[@sbohatch805]

I LOVE your program and how you analytically present all the known information and make clear what isn’t confirmed data. I can’t imagine the amount of research you do coupled with clearly a strong knowledge base of both the medical and fight communities. I love every opportunity to fly-especially takeoff and landing-but have no interest in pursuing and maintaining a license. I am a geek toward understanding all that you cover. One of my best friends son recently got his pilots license; I was amped to use what I’ve learned so far from 4-5 of your episodes in several conversations with him and learn more still from his training. Keep up the phenomenal work!

[@jordancoleman2402]

I live in Lacrosse and don't remember this happening, thank you for covering it 👍

[@MrJones-uq5cg]

I don’t know if you made this as a response to my earlier suggestion, but thanks so much for all the effort you put into it.

[@youwebz]

The cool bit of a helicopter is you can stop, hover and land if the wx gets bad. Pushonitis is a terrible disease.

[@steveb1739]

An absolutely professional and concise presentation! Thank you Doctor.

[@TheDrMedic]

You're very welcome!

[@poppabear9279]

I thought this was going to be the story that I actually witnessed the air ambulance crash in a fireball in ClearLake California back around the same time. It was raining very bad and flew it right into the mountain.

[@Mattolordlights]

I fly these helicopters for the army NG, UH-72/EC145. It’s a fully capable aircraft to fly alone on a great wether day but personally flying in a SVFR situation where weather said it was MVFR and was really IFR/LIFR. Having 2 pilots makes the situation a way less stressful. One in the control focusing on instruments flying the aircraft and other talking in the radios giving instructions.

[@SaundraDiStefano]

I think dual pilot IFR would be the most ideal. The problem is there's already such a shortage of even VFR-only HEMS Pilots. Finding enough IFR rated pilots, much less 2 of them per shift (that would be 8 pilots per base!!!) is probably just my wishful thinking. Especially when flying in an area like where I'm at (Houston) they can be so task saturated between med Crew needs, talking to the tower and talking to the HEMS dispatch as well.

[@angeloftheabyss5265]

Isn’t it strange that organizations that pay well have no problem hiring pilots? Single pilot IFR operations for hire should be outlawed.

[@chrisjohnson4666]

That's what metro does twin pilot IFR... They have very strict weather limits...

[@oledahammer8393]

I'm not a pilot, but I have never understood this...why not determine the highest land elevation between your current location and the destination and make sure you are well above that point shortly after leaving your current position until you reach your destination. Then, there is no possible way you can run into anything ground based. Then, regardless of visibility, you still could not ever impact the terrain. I'm sure I'm over simplifying it, but that is what I would do. So, if the highest point between LaCrosse and Madison is 1200 ft above sea level, I would fly at least 1500 ft above sea level and there's NO possible way I could hit anything, right? Why is it not THAT simple.

[@Starfish2145]

Makes sense to me!

[@gsresener]

I think that, one topic that you have already talked about, is the importance of the medical crew being part of the aircrew and having an active voice during the mission planning and flight. Sometimes the medical are more used to the region's terrain features and weather (specially when there's pilot rotation). Also, looking forward your helmet video, trying to implement it in our service

[@med1pilot1956]

That was our program that turned down a second flight to that area. On the return from that area our pilot said weather was closing in quickly and he would not go back.

[@TheDrMedic]

Very sad. Fly safe @med1pilot1956 👊

[@ScottPerkins-sp5mx]

I enjoy and learn a lot from your videos. Will you please do a video on the Duke Life Flight crash that occurred in north Carolina on September 8 2017.

[@catchthewind8563]

EMS flight crews should always have the best equipment and best trained crews. I don't know who does the funding, but training(including contingency and preparing for emergency scenarios), equipment, and high standards for crews are extremely important for the safety of the crews amd patients they haul on their flights.

[@ericconnor8419]

As a British person it is very surprising that Americans can afford to operate such expensive health infrastructure. We have a few air ambulances here but they are run as a national charity not a business. They are only used for things like big car crashes. I have never heard of a hospital or university operating its own aircraft, especially shiny new helicopters with night vision goggles! Private healthcare here is for the rich, I don't think I could afford it, certainly not if the hospital was operating equipment like this. I would rather take my chances in an ambulance instead of worrying about bankruptcy.

[@r2db]

Having personal knowledge of some of the items discussed, you seem to have done a lot of homework for this. The biggest inaccuracy I noted in your video is that the communication specialist was not an Air Methods employee. Only the mechanics and pilots were supplied by Air Methods. The flight nurses and communication specialists were hospital employees, and the flight physicians had clinical faculty status with the School of Medicine and Public Health and were employed by the organization that managed university-owned medical practices. The difference in employment of the crewmembers had the potential for some safety concerns, but for the most part it was a non-issue. Immediately after the crash the program insisted upon TAWS and NVG-compatible cockpits in all aircraft, helmets were always worn, all flight crewmembers were trained on NVG use and required to maintain currency, and with the exception of when dual controls were installed due to pilot proficiency checks the flight nurse or flight physician would be up front with the pilot when a patient was not on board. If the dual controls were installed and the engines had already been started before the medical crew boarded the aircraft that was the only situation where the pilot was alone up front without a patient on board. For a landing with NVG use a crewmember in the back in a rear-facing seat was required to be current with and also using NVG.

[@billvandorn5332]

An outstanding summation with the forensic analysis for the primary and possibly secondary causes for this tragic event. Without these forensic analysis we would not get better in the disciplines of services rendered. The Logical solutions to avoid these tragedies often cause increased Financial liabilities which many people do not think worthy of or perhaps think they can get away with not employing these costly improvements. I'm not sure if I missed the vocation of a checklist with a flight plan. Not directly related to this incident, I remember it taking many years and many reports trying to get delineator markers and warning lights posted on the nearby electrical and telephone lines and Street lights at a nearby landing and departure route in close proximity to a landing pad!

[@user-re4hc7yf2m]

Love your videos. Keep making the podcasts too!

[@SimonAmazingClarke]

It is an unfortunate fact that all safetyregulations are written in blood. As well as the other factors mentioned, get home itis is a powerful force that is hard to prevent.

[@georgesheffield1580]

This similar thing happened a little over 30 yrs ago killing a bunch of musicians in that part of the US including Stevie Ray Vaughn . flying into the ground .

[@camjcasey]

Your research and knowledge of aviation is incredible.

[@teeroux]

A toggle switch which is on a panel, that was dislodged from an aircraft whilst falling through trees and brush. Did the investigation team not think that maybe the switch changed positions from idk getting dislodged and tumbling down a fucking moutain?

[@dimitri1515]

The problem is that even in 2023, the commercial helicopter industry is still almost 20 years behind the commercial airplane industry.

[@Starfish2145]

How come?

[@dimitri1515]

@@Starfish2145 Not enough oversight. Not sure why the FAA doesn't have more control over that industry. OR if it does, maybe they just don't care.

[@44hawk28]

I worked avionics and automated flight control systems on the F-111 long before this accident ever occurred. I worked on a number of different aircraft including f-14s, f-4s, even got to work on Daryl grenamyer f-104. I wrote up a pilot one time for improper or faulty operation of the aircraft because I retested the aircraft three times in the only way I could get the malfunction that he described worker was by putting the switches in the wrong configuration. I had a four-hour running argument with a sergeant the next day over him telling me that I did not have any authority to tell a pilot he didn't have a clue how to operate the aircraft. 6 weeks later the same pilot crashed on aircraft by not following procedures outlined on how to fly the F-111. I didn't know that it was this pilot, I didn't even know his name. But I was on the flight line with our headsets tune to the flight Channel and listening to the pilots talk as he crashed this aircraft while doing touch-and-goes. I was completely surprised when I was called into the investigation because I was the only one, even though many people had talked about how inept this pilot was, I was the only one who would actually documented that he didn't know what the hell he was doing. Whenever you get somebody who's an outlier and tells you that this is what happened. He probably knows what he's talking about. Especially if he's sticking his neck out against the group. This One Singular NTSB official that decided to claim that it was the operating organization that was at fault, was dead on. I have consulted with the FAA during the problems that they were chasing down the issues with the 737. The information I did not know, because my aircraft the F-111 never flew at high altitudes but rarely. So I had no experience with the extreme cold that the aircraft suffers and then what happens when you start running hot fluid through it but I did know that the problem was being caused by the rudder actuator. I told Ted Hovenga that Bunch before the final crash which was where they finally found the problem.

[@jmWhyMe]

It's ridiculous that HEMS flights don't have two pilots. The workload for a single pilot is overwhelming. Further, if you're going to fly in the Midwest you MUST be IFR proficient, and if you're going to be a HEMS pilot, you must be like a military pilot, able to think on your feet and be flexible and fly unfamiliar terrain. These companies do the cynical calculus that the cost of a crash is far less than the cost of proper staffing, training and maintenance, because they monetize human life with cynically low values. Until the Government and Insurance industry start severely penalizing companies like this, little will change...

[@ralphbove]

Man, So much to say but I will stay out of it for various reasons. I knew all these folks (RIP). I worked in HEMS and flew in the IL/WI area for over a decade and worked for the vendor in various capacities for a long time for another decade after that. You did a nice job with this presentation. Good work

[@drewapple9681]

When I was about 17 back in 89 I watch a air med helicopter run into a small Cessna killing everyone Out of Houma Louisiana about 1989 to 1990.

[@latetotheparty184]

"Scud running" a pilot just trying to make it through the fog and over the mountain or hill. I like this new word.

[@sallyb7472]

We can hope that bringing this up and picking the incident apart is to prevent future incidents. There is no malice or ghoulish intent for anyone who may not understand the purpose.

[@amd77j]

Condolences to all those who lost their lives in this tragedy.

[@PNW_Car_Mods]

We have the direct sister ship to this aircraft at our program as this is typed. N235UW Formerly known as. Fun fact, our program has had at least 3 hand me down choppers from University of Wisconsin. Haven't watched the vid as I really don't need to relive these accidents but I can say that this accident was one of many in a short time period for EMS.

[@PNW_Car_Mods]

This accident would have likely been avoided had HTAWS been installed on the aircraft. Safety costs money though so therefore you can't have it all.

[@Redmenace96]

@30:00 the addition of Robert Sumwell's observation was important, I think. The pilot was pressured into the situation, as many are.

[@scottmoseley5122]

Very well researched and presented. Great job.

[@deborahchesser7375]

So basically even a highly regarded company with some of the best pilots and aircraft can fall victim to a series of unforeseen events and the odds of eventuality. That’s pretty spooky

[@AndyBodkin]

dual pilot will likely never become a standard practice in US HEMS unless the FAA requires it. So many programs in the US are in airframes that can not accommodate a dual-pilot crew. All of the big corporate programs would have to completely replace their fleet (or much of it). Astarts and 407s can not run a dual pilot and have a stretcher in the aircraft. I seriously doubt Air Methods, PHI, GMR etc can replace 80% of their fleets with 135s 145s, 429's etc which would allow 2 pilots. However, I think dual pilots would be the best and safest way to fly. None of these companies will do it.

[@jamesharp3445]

Former Army Helicopter pilot here. I can say this with absolute clarity: Any helo pilot who thinks that they can fly single pilot IFR proficiently and safely...is a complete idiot. Fixed wing... totally different. A single pilot flying true IFR in a helicopter will always be behind in the aircraft. Anybody who thinks diffently needs to take a ride in a carbon fiber deep sea submersible. The law for medical companies has to be 2 pilots required for each flight. Period.

[@justinhaase8825]

My brother was a flight nurse for a few years…and while a plane guy for decades, ignited my interest in helo. I agree…flying helo is a full time job VFR…IFR is an entire other situation. We have a Med IFR 135 op here that as far as I know is single pilot but I’ve seen them out of the soup a couple times… My bro has told me many details for crashes such as the St Louis and St Joseph on here that the channel guy may or may not know but can’t quite put out. But he has also told me of so many grandparents dying 3 hrs away for family a week later or the next couple days locally. The few truly medically needed flights are rare…but gray areas areas are the profit center. Most situations are already determined before med crew arrives.

[@TheRotorhound]

Scud running vs going IFR illegally and living.

[@427SuperSnake1]

I think that medical helicopters in the US should have an observer sitting up front, not a flight nurse but a dedicated co pilot so to speak, although they don’t need to be certified as a pilot. But someone who has flight experience and knows procedures, checklist and is NVG certified. Also they need to be more strict about Helicopter shopping when one provider turns the flight down for weather. Helicopter shopping has been a contributing factor of a lot of fatal accidents.

[@jackimo22]

Idk what it’s like in the states, but in Australia we have two pilots (pilot & crewman) along with a doctor and a paramedic/nurse on every aeromedical flight. We deem the risk of single pilot flights far too dangerous for transfer, retrieval and rescue flights.

[@kyegunn3699]

What is really sad about this crash is that an EC135 is a very simple aircraft to fly IFR. You don’t have to be a great IFR pilot. You just have to know the basic function s of the autopilot and how to select an approach on the GPS. That’s really it. I’m thinking the pilot may have “punched in”, lost visual, then panicked, forgetting to climb, climb, climb. He may also have been sucked in by a false horizon; getting visual cues leading him to believe he would clear the bluffs. We just don’t know. Was he knowingly scud running? Who knows. Maybe. Terrain clearance and how to determine what altitude that will be is taught during the first few hours of primary flight training when being taught cross country planning. If cloud decks do not allow a pilot to reach that altitude….thats an aborted flight or a no go. Very, very simple. Obviously, unforecast weather can throw a pilot a curveball en route. Responding properly is the key. After flying EMS for the past 20 years, more than half in an EC135, what has become glaringly obvious to me is that if a pilot cannot fly comfortably on instruments and set up and fly an approach, they have no business flying an EMS helicopter.

[@johnwayne2103]

So the equipment that should be standard on most aircraft was not purchased but they had no issues buying 4 brand new helicopters. Instead of just buying 3 and using the 4th one to offset the extra expense of adding the additional equipment. Got it. Everyone know why the Seawolf Submarine crashed? Well here's a little story they had 2 DME's. One was broken so they set out to sea because it was "an acceptable risk" and who knows what else was the priority. So they relied on the one DME and for some odd reason they decided to forgo reporting their distance from the bottom for over an hour or more. CRASH! Lot's of reasons but sometimes safety and logic seem to escape everyone.

[@goldeneaglejk2678]

Was the flight REALLY necessary????? Or was this just another case of send the helicopter because we need to bill hours to cover the cost of having a helicopter? The over use and high billing cost of helicopters is a real problem in the US. I was SHOCKED to learn that they are allowed to use night vision! It is incredibly dangerous as it limits your field of view and situational awareness. I am surprised we don’t have more crashes like this one.

[@carolfrazer8067]

I live in this area. You have no idea what it’s like. Our small communities do not have trauma units and need larger hospitals with trauma units. The drive from Prairie to LaCrosse is narrow and dangerous. It is very close to the Mississippi River. Lots of deer and other animals along that route. I don’t remember why the patient was transferred, but they needed more critical care than Prairie could offer. Hensley the flight.

[@LichaelMewis]

Excellent break down. Agree with all your points.

[@st05002125]

Single pilot still works well in the UK, but I think the attitude to task is different than the US as generally a charity based response in the UK, not a commercial decision.

[@st05002125]

To clarify single pilot with TCM.

[@nicolad8822]

Yep, our local Air Ambulance service has only recently started flying at night.

[@LatitudeSky]

The UK approach to HEMS has always seemed much more logical to me. The community supports the service for benefit of all.

[@PaulHockey-yu8fe]

Great analysis, report and Presentation

[@ron6892]

Been there, done that, got away with it……..I still shake my head at how stupid I was…

[@Shouk02]

I think that the very oversimplified conclusion is that pilot should not have flown that flight. If VFR was so intermittent with changing weather conditions only pilots with IFR ratings should be flying.

[@paulchevrier9961]

Excellent video. I'm not all all involved in the aviation or medical industry. But I consider myself a student of disaster investigation. One thing that I have noticed in the majority of small aircraft crashes, is the use of one pilot. I can understand single pilot in the private pilot license category. But as soon as we enter the world of commercial pilot flight, all flights should be required to have two pilots. I do realize that would raise the cost of every flight, but commercial flights are and have to be held to the highest safety standards. There is some much happening in the cockpit that 2 pilots are needed to do the work and make the necessary decisions to safely operate the aircraft in a commercial setting. So in this case it might have cost $200,000 more money to safely operate this aircraft per year. But instead this accident cost 3 highly skilled professionals their lives, the loss of a $5,000,000 aircraft, probably a $1,000,000 for the investigation and how many more millions in lawsuits for the victims families.

[@pickles3128]

Is there a bracelet or something I could wear denoting that I don't ever want to be airlifted if injured? Don't want to have my wages garnished for the rest of my life paying the 100k bill, nor my family.

[@mattl1811]

Ground transportation isn't cheaper

[@pickles3128]

@@mattl1811 $300 is the flat rate without insurance for transportation. My stepdad fell on the sidewalk across from the hospital. No discount.

[@robertbandusky9565]

Give me a break! Under 4 hours IFR in four years?🙏🏻

[@Bobm-kz5gp]

I have to give you credit for your knowledge of just about all medivac helicopters. I flew for Air Evac Life team. Luckily I had quite a few flying hours, 13,600+, 3600 in RW and the rest in airplanes. 10 years in the Army, 17 years with American Airlines, then 10 months teaching IFR flying in worn out TH67’s, decided Medivac flying would be more satisfying. I was based in KY for a month then transferred to Jesup Georgia for 3 years and 268 patient flights, the most satisfying flying, not bad pay at 70K for 1/2 a year, retired at 67, didn’t want to take the chance of having a stroke or heart attack in flight.

[@thatguy8005]

‘Experts’ still don’t know how to get out of vertigo. Inadvertent flight into instrument conditions never happens with a pilot flying straight and level. There head is turning looking for where to go vs. instrument flight with their head almost still with eyes scanning the instruments. When a pilot enters the instrument conditions if they changes an aircraft’s attitude before having eyes on the attitude indicator when the attitude indicator shows level and the pilot attempts to stop the aircraft at level flight, the fluid in the ears continues to move giving an off balance feeling that doesn’t match what the eyes are telling the body from the attitude indicator. This feeling induces a sea sick kind of feeling. Pilots tend to turn to get their body to feel better. Even if they don’t turn, and stay on the instruments, the flight is likely doomed if no action is taken to stop the sea sickness feeling. My recommendation is to shake your head in an attempt to reset the fluid in the ears until it no longer disagrees with the eyes. If you are unable to reset the balance of the eyes and ears, the pilot will get sick. Ever try to fly throwing up? the aircraft crashes before the pilot can get sick.

[@colbypupgaming1962]

I remember seeing this accident on the news. There was another accident a couple years before in my hometown. Maybe the Eagle III accident may be worth doing a video on?

[@Parkhill57]

The pilot should have climbed on top of the weather. If Madison was socked-in, they could of went to 50 other places and got a motel and enjoyed a good Tavern with a fine meal.

[@josephkanowitz6875]

ב''ה, if the certification isn't there, are they authorized for that climb?

[@Parkhill57]

@@josephkanowitz6875 Yes, ATC won't force you to kill yourself scud running. (well, intentionally anyway).