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Celebrating Decision-making

Celebrating Decision-making

High-Altitude Army Aviation Training Site
Gypsum, Colorado

Celebrating decision-making sounds about as exciting as celebrating the move from fifth grade to middle school. But decision-making is the key for a successful day that involves multiple search-and-rescue missions flown in the high country of Colorado.

People like to celebrate the hoist operations we conduct at 14,000 feet or the one-wheel landing that made the news because that’s “sexy.” Even as pilots, good decisions are rarely applauded, but you can bet your wings a poor decision will be revisited more often than you would like.

As the commander of the High Altitude Army Aviation Training Site, I have multiple levels of risk to evaluate. In training, I must trust that my instructors can read a student quickly, challenge that student by pushing their limits, yet allow learning to take place without damaging the aircraft. This is high frequency because the training is conducted weekly and low probability because of the experience of my instructors. What makes the hair stand up on the back of my neck is search-and-rescue decision-making.

SAR for the HAATS tends to be a medium-frequency, high-risk mission. Medium frequency meaning we flew 29 missions last fiscal year, so there’s some familiarity, but still high risk for a multitude of reasons. In addition to “normal” risk associated with flying in the mountains, SAR missions can become complicated quickly. These complications arise from variables such as relying on SAR teams as our ground counterpart, the elevations where people get lost or injured in Colorado, the severity of the situation before we are notified, the expectation of what we are supposed to be able to accomplish and the ever present sense of urgency.

On July 11, 2015, we received a call about two missing hikers around Mount Blanca. Flight for Life Colorado, whom we work with quite frequently, was also called to search because it was presumed that since the two had been missing for two days they were probably in need of medical attention. Ground teams began to move into the area and FFL was able to locate the two individuals. Due to the terrain they were in, it was decided a hoist operation might be needed; in any event, FFL was not going to be able to land near them.

The crew received this information after launching and landing at the incident command center for a face-to-face briefing on the situation. This was a first good decision to set the tone for the day — land and talk to the individuals controlling the operation. A face-to-face typically alleviates any misperceptions we may get from translating the situation through numerous operations centers. It also updates information that changed since our dispatching.

It was especially important in this case since we do not work with this county often and communication available with the field teams was already in question. This also prevented us from entering the search area and being surprised by FFL. Even though we have a memorandum of understanding with them that places us on a common frequency, we typically forget to blind call or even tune it up at times if we do not suspect they are there.

After receiving accurate latitude and longitude coordinates, the crew launched to assess the situation. It was determined it would take hours for the ground team to get to the victims. About this time, we received word from Mountain Rescue Aspen about a follow-on mission on Mount Snowmass for a fallen climber. This was relayed to the crew roughly at the time they arrived over the survivors. They decided that it was just as easy to pick up the two seemingly OK survivors and save fuel for the possible follow-on mission.

We have a SAR standard operating procedure that calls for us to land first, use a two-wheeled landing second, a one-wheel landing third and hoist as a last resort. Since there were no ground teams onsite and wouldn’t be for a few hours due to the terrain and three- and two-wheel landings were not possible, a hoist was determined to be the best option.

We do not have medics at HAATS who are well trained in riding the hoist down to assess a victim. Because of this, the crew chief went down on the rescue seat, making this the second decision to celebrate even though this was out of the norm. This gave him the opportunity to assess the survivors and determine if the seat would work. More importantly, he made sure they were securely attached to the seat vice, relying on them being able to read and comprehend the instructions on the seat after no sustenance for two days.

While conducting the hoist work on Mount Blanca, back at HAATS we received word from the Colorado Joint Operations Center of a third mission that was approved and became the next priority. A female hiker who happened to be 10 weeks pregnant had fallen on Crestone Peak and had a possible broken femur and ribs, difficulty breathing and was becoming hypothermic, as reported by her hiking partner.

Crestone Peak and Crestone Needle, like so many mountains in the Aspen area, are nasty places to work and one of the few places that make me cringe when we have to send aircrews there. The crew was going to Alamosa for fuel, so we decided to talk to them by phone when they landed to give them the follow-on mission, hopefully with a little more clarity. Although not celebrated at the time, this decision slowed the operational tempo and allowed us at HAATS to coordinate ground teams and talk with a good connection. Slowing the OPTEMPO is sometimes difficult, especially with a victim like this, but it is necessary to prevent pushing a bad situation. One thing we like to reiterate from time to time for both our aircrews and ground team members is: “Don’t make their emergency your emergency!”

It was pretty evident that this mission was going to require a hoist. Patient packaging is not our forte; we rely on the SAR teams we work with for that. As luck would have it, the team from Western State we had trained for hoist operations during the spring were on their way there from Gunnison. It was decided to have them go to another airfield, where we would link up with them and a team from Saguache County, insert the teams, package the victim, then hoist and go. It was also determined this mission had the possibility to run into night, which meant the crew would fly with night vision goggles.

At this point, it was determined crew rest was not an issue, so we adjusted the risk accordingly and didn’t have much in the way of mitigation to apply yet. Now it was time for the real “decision party” to begin.

While en route to Crestone Peak, the aircrew was notified that FFL was taking the Snowmass mission. After picking up the Saguache team and locating the survivors, the team was inserted. The survivors were on the leeward side of the mountain, in a steep drainage on an “island” of sorts made of one large rock and running water on both sides from the melting snowpack above. There was no place to land near the injured party, so the team was inserted as close as possible and would have to traverse the couloir to make contact with them. (Coincidentally, one week later we would be back at the same spot for a climber who was not so lucky and missed the island in the fall and subsequently died.) The aircrew went back to pick up the Western State team, donned their NVG and inserted them to package and hoist the survivor.

The teams made it to the survivor, packaged her, and were ready for the hoist. The Black Hawk is a powerful machine, but, at 14,000 feet, even it has limits. Operating on the leeward side of the mountain, the downdraft and turbulence was so strong that maintaining a stabilized hover was virtually impossible.

Working backward now through our SAR SOP from hoist to landing had to occur. I say backward because now the ground team has to move the survivor with ropes in unforgiving terrain. Their safety had to be balanced along with the capabilities of the aircraft and crew. This was the best decision of the night and the reason to tell the story: moving away from the hoist and opting to land, sacrificing speed and the "hero" image that comes with doing a live hoist. It was also one of the hardest for both the ground teams and the survivor to hear.

The turbulence was bad to the point that a one-wheel landing was not going to be stable enough to load the survivor over the rugged terrain. Two wheels was marginally better, and there wasn’t a place for it to be executed. Unfortunately, the team would have to move the survivor 1,500 feet vertically down the mountain, possibly at night with no illumination, to where the aircraft could get all three wheels on the ground to load. The decision became complicated because there was a serious concern as whether the survivor would make it through the night given limited medical support available from the SAR teams. This was a tough decision to make given the circumstances but the right call from a safety standpoint.

The aircrew went back to Alamosa for fuel and planned on returning at 0100 for pick up and a status check since they were going to be out of communications with the team. Meanwhile, the rest of us in the HAATS Command Center were beginning to wonder what the issue was. I know from our experiences with fallen climbers about how much time it takes to complete the complicated portion of the mission, and I am respectful of the workload going on in the aircraft enough to stay out of the cockpit, but the lack of contact was becoming disturbing. We finally received a call from the aircraft when they were back in Alamosa about what the proposed plan was.

Now I had some decisions to make as a risk manager. I understand they do not want to leave the victim or the team in the field, but I have to be the one weighing the risk versus the reward. The risk was that this crew had completed one mission and was just jerked around on another mission, only to end up on this mission. They took NVGs with them, but those were for recovery purposes.

Flying unaided in the mountains of Colorado can be a death sentence. We had not cycled the crew for NVG, so they had been at work since noon and were going on nine hours of duty day already and the pickup was not until 0100. Pickup at 0100 placed the most dangerous portion of the mission in the 11th hour of their duty day and they still had a two-hour flight home to HAATS on top of it through the Colorado high country. I know they have not eaten and probably hadn’t hydrated much. I normally wouldn’t worry so much about a person’s diet, but I also knew they only had two small bottles of oxygen each and had probably exhausted one so far, so I was concerned about hypoxia adding to the issue.

We discussed all the variables and why the crew made the decision not to do the hoist. I had to make a decision whether they should go back and pick up the victim or trust that she was in good hands to this point and was going to be able to be roped down and carried out. At a minimum, the crew needed to make contact and let the ground team know what was going on, which could happen on the way home. There was a waiting air ambulance on a soccer field in town, but that is as “remote” as that aircraft’s contract would allow under NVGs.

So, the carry-out of the victim would be a long and arduous process. A victim who was 10 weeks pregnant and suffering from hypothermia, broken ribs and a broken femur in the backcountry factored into the situation. We are not heartless, so it was decided that the crew would return at 0100. If the team made it to the pickup zone and a safe extraction and delivery to the awaiting air ambulance could be conducted, the mission would continue with some mitigation.

First of all, and not because I was worried about the crew becoming Aretha Franklin-like in the Snicker’s commercial from a lack of food, they needed to eat. They were able to coordinate late-night food with the airport. Secondly, they needed to make sure they were good with oxygen for the pickup and the trip home. As luck would have it, the first mission was only around 12,000 feet mean sea level and was executed fairly quickly, so they all had oxygen remaining. Finally, the last and most critical item to manage at this point was crew rest. They assured me they felt OK now, which didn’t matter to me because they were coming off adrenalin and the critical time to be awake was over four hours from now. I urged them to try to nap but, having experienced it many times myself, I knew it is hard to turn the brain off during a SAR knowing you have to go back out. Sleep is difficult at best.

I could only offer some mitigation. I could order them to come home, but I was not sure my conscious would allow me to do that. First of all, it was easy for me to say that being back at HAATS Command Center and not out there in the field. It was reiterated to think of the crew before the victim or the SAR teams. If they had an accident, they were making that victim’s emergency their emergency. This was not lost on the crew.

Second, and most importantly, they were going to have to cross-monitor each other’s performances. I was not there to watch the crew, and, truthfully, only each crew member knew how tired he was. Externally it could be faked for the most part. The crew was familiar enough with each other that they could hopefully identify mistakes being made in performance/load calculations or just normal crew procedures and use it as an indicator to determine if the risk was increasing.

Third, if the ground team was not successful in moving the victim to the PZ, they had to determine what additional time and coordination must take place. If not executed quickly, they may have to leave them all in the field and return home. There was no going back to Alamosa for fuel and they still needed about two hours of fuel to get home. Finally, and I hate doing it, especially to the all-volunteer SAR teams who, incidentally, are the true heroes in this and all our SARs, the ground teams would have to walk out. We assumed all the risk to get the victim out and the very capable ground teams could handle the hike and coordinate for transportation.

As the commander of the HAATS, I only get to manage the risk at my level to the best of my abilities. In the state of Colorado, ultimately the adjutant general, who is the two-star leader of both the Army and Air National Guard, is the one that has to approve the highest risk level. My conduit to him is through the state Army aviation officer, who happens to be my predecessor in this job and is well versed about the ins and outs of these missions. I rely on his tutelage since I still haven’t seen it all and his ability to articulate to the TAG the risk he is about to assume. This is extremely important because sometimes senior leaders will assume risk while not fully knowing what they are assuming, to which we owe them a detailed explanation so they can make an informed decision. With the mitigations in place, he trusted the team and allowed the mission to continue.

I do not know that the decision to go back and pick up the victim is a celebration-type decision; it was just a decision. It was calculated and mitigated, and the crew was airborne again at 1245. Once they were in radio range, the SAR teams communicated that they had the victim in the designated PZ where all three wheels could make contact with the ground. Their efforts saved this individual and, as I understand it, the baby too. The landing on the soccer field and subsequent transfer to the air ambulance went quickly, and the crew was on their way home.

Incidentally, the cross monitor piece I spoke of earlier paid off. On the return trip home, one of the crew members became Aretha Franklin-like. Probably the most benign portion of the mission vice being under NVGs and this crew member became knit-picky about every task that was occurring at the time. Simultaneously, all the crew members told him to get back on oxygen, and Aretha disappeared.

What occurred on this mission paints a picture of the work we do and the risk involved. Working at altitude in an unforgiving environment means every decision is critical. Our crews, command and support personnel understand this and manage the risk on every mission. The process applies to everyone in Army aviation.

  • 1 February 2016
  • Author: Army Safety
  • Number of views: 1267
  • Comments: 0