A fighting chance: Surviving pilot incapacitation

The first sign of trouble came in the form of a question.

Like Many air medical crewmembers, Lane Abshire had wondered in the past what might happen if his pilot were to have a medical emergency in flight, but had never considered it a serious possibility. “And then to be actually living it … I [had] to convince myself it was actually happening,” he said. Air Evac Photo
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“Where are we going?”

It was Jan. 12, 2018. The Air Evac Lifeteam helicopter had just lifted from a scene call near its base in Kinder, Louisiana, north of Interstate 10 between Lake Charles and Lafayette. The patient was a frail, elderly woman who had been sedated and intubated on scene.

In the back of the Bell 206L LongRanger, flight nurse Tara Coupel and flight paramedic Lane Abshire were attending to the patient when the pilot’s voice came over the intercom: “Where are we going?”

“Lafayette General,” Abshire replied, referring to Lafayette General Medical Center, around 50 miles (80 kilometers) to the southeast.

“OK, where?” the pilot asked.

Abshire and Coupel thought at first that there was a problem with the intercom system. They unplugged their helmet cords and plugged them back in; tried telling the pilot again. But he repeated, “OK, where?”

The helicopter was now about 800 feet over the ground. Abshire asked Coupel to get out of her seat and tell the pilot where they were headed. She unbuckled her seatbelt, removed her helmet, and moved forward to tap on the pilot’s shoulder.

“Lafayette General!” she shouted at him. Although she was disconnected from the intercom, she could see him mouthing the words beneath his mic boom, “OK, where?”

Coupel returned to her seat, put on her helmet, and plugged in. “Lane, something’s going on,” she said. It was around that time that Abshire realized they were flying in the wrong direction.

“We were in a left-handed bank, and we were flying in a left-handed circle,” he recalled. “And I’m like, something’s wrong.”

There’s not much room in the back of a LongRanger equipped as an air ambulance. In Air Evac’s medical interior configuration, the stretcher is positioned on the left side, with the patient’s feet in the position that would normally be occupied by the co-pilot’s seat. A structural metal bar extends over the patient, behind where the co-pilot’s shoulders would be.

A view of the cockpit area in a typical Air Evac helicopter. Air Evac Photo

As Abshire explained later, “on any other given day in south Louisiana, it’s nothing for us to transport 200-pound, 250-pound patients.” But their patient that day was a scant 85 pounds (40 kilograms), giving him just enough room to squeeze between the patient and the bar once he removed his helmet.

“I managed to crawl [over] her and get all the way to the front of the aircraft. And when I got to the front of the aircraft, I hit [the pilot] on his shoulder, and when he looked at me, my heart just went in my throat. Because he looked straight through me — he had that thousand-yard stare.”

It was now apparent to Abshire that the pilot was having a serious medical emergency. When he looked back at Coupel, she realized from his expression that they were in trouble. She was terrified.

“That split second after he turned and looked at me with that look, I thought we were crashing,” she said. “I thought that was it. I actually pulled out my phone, texted my mom ‘I love you,’ and put it back in my flight suit.”

“She was emotional, and I was trying to hold it together,” Abshire recalled. Because he had removed his helmet, he had to shout at Coupel over the noise of the engine and rotor.

“I yelled at her, ‘Call mayday . . . get on the radio and call mayday, this is happening,'” he said.

“You know, you always talk about calling a mayday, but when it got down to that point, I had to convince myself that it was actually happening. You talk about it all the time, you practice it, but like, no — this is for real.”

An unprecedented call

More than 500 miles away in O’Fallon, Missouri, Tim Cincotta was sitting at his desk in Air Evac’s operations control center (OCC). Cincotta is a commercial fixed-wing pilot who has worked for the company as an operations control specialist since 2010, tracking flights and weather and evaluating line pilots’ risk assessments.

Tim Cincotta was the operations control specialist who communicated with Coupel during the event. Air Evac Photo

That Jan. 12, nothing he had seen in his eight years on the job had come close to what was happening in Kinder.

Air Evac’s headquarters in O’Fallon includes a central communications center, or “cen comm,” as well as the OCC. Typically, cen comm specialists are the ones who liaise between dispatching agencies, the company’s aircraft, and receiving hospitals, and are therefore the ones monitoring radio communications at all times.

But on this day, another OC specialist happened to be monitoring the specific “tower” frequency that allowed the ship from the Kinder base, Air Evac 125, to communicate with headquarters via radio over internet protocol.

“He said, ‘Hey, I think I heard a mayday call from 125,'” Cincotta recalled. Cincotta opened up the tower frequency and spoke to Coupel, who reported that their pilot was unresponsive. “I’m thinking, ‘Oh gosh…'”

Pilot incapacitation is never a good thing, but in a light helicopter flown by a single pilot, it is close to a death sentence. A standard LongRanger certified for visual flight rules (VFR) has no stability augmentation system (SAS), no autopilot, none of the inherent stability of an airplane. If the pilot ceases to actively fly the aircraft, control will be lost within seconds.

Fortunately, this was not a standard LongRanger. Air Evac had recently completed the multi-year process of equipping its fleet with Genesys HeliSAS stability augmentation systems and autopilots, along with Garmin GTN 650 GPS units and G500H glass cockpits. All of these were on the aircraft in Kinder.

According to Air Evac director of safety Tom Baldwin, when the company made this substantial investment in autopilot technology, its primary concern was inadvertent flight into instrument meteorological conditions (IIMC). An autopilot can be a lifesaver when a VFR helicopter pilot wanders into the clouds, and from that perspective alone, he said, “the technology has paid off in spades.”

This photo of a typical Air Evac medical interior shows the metal bar that Abshire had to climb under to reach the cockpit. Air Evac Photo

Now, Cincotta recognized that the HeliSAS also represented the crew’s best chance of survival on this clear sunny afternoon in south Louisiana. He asked Coupel whether the autopilot was engaged; back in the helicopter, she shouted the question at Abshire.

“I wasn’t aware at the time how to actually tell on the controls if the autopilot was engaged . . . but I felt like [it was] because we were holding a steady attitude,” he recalled. “So I was comfortable in assuming that the autopilot was engaged.”

By that point, Cincotta had already concluded that the HeliSAS was functioning; otherwise, the aircraft never would have flown so long with an unresponsive pilot. As he put it, “had the autopilot or SAS not been engaged, they probably never would have called.”

But HeliSAS was still new to the company, and the OC specialists had never had a reason to learn the system intimately. They scrambled to find maintenance controllers and simulator instructors who could advise them; nevertheless, Cincotta felt increasingly pessimistic about the crew’s chances.

“I’m thinking that if this pilot is deceased or can’t come back, this is not going to end well,” he recalled. “I honestly thought, ‘I’m talking to a lady that’s about to lose her life.'”

‘There’

Meanwhile, in the cockpit, Abshire was desperately trying to get through to the pilot.

Having survived his experience, Abshire believes that the most important thing to do in an emergency is create and maintain a “task orientation” to keep from locking up. Air Evac Photo

“I was trying to get him to go back to our base, trying to just spark some kind of familiarity with him, and he just wasn’t doing anything,” Abshire recalled. “Then I was trying to get him to land in every field we flew over, and he just kept looking at me and staring at me and he’s like, ‘Where?'”

Although the HeliSAS was engaged, the pilot’s right hand was still on the cyclic, and the aircraft kept banking to the left. Abshire put his hand on the pilot’s cyclic hand and helped him level the aircraft. They were still flying, but Abshire didn’t have an endgame.

“There was a point in the flight where my brain had legitimately accepted the fact I was going to die,” he said. “I started thinking about my family and my kids, and I just kept asking God, please don’t let me suffer. I don’t want my family to see me suffering. If this is going to happen, just make it quick.”

Then, randomly, the pilot looked away from Abshire and toward an open field in front of them. “There,” he said.

“Yeah!” exclaimed Abshire. “There! Put it down there, just nice and easy.”

The pilot went for the collective and the helicopter began to descend. Abshire yelled at Coupel, “This is it!” He knew that the autopilot would disengage as they slowed and approached the ground, and his anxiety was intense. His hand was still on the pilot’s cyclic hand, helping to correct for left drift.

Alone in the back, Coupel was surprisingly calm; the familiar feeling of a smooth, controlled descent put her at ease. “Which is crazy, if you think about it . . . no big deal, when this is essentially the moment that’s going to decide what our fate is in this aircraft,” she said.

But the smooth control continued all the way to the ground. In fact, she said, “that probably had to be the most controlled, gentlest landing I’ve had thus far in an aircraft — it was just perfect.”

Abshire later speculated that the experienced pilot, who had retired from the U.S. Army, drew on “muscle memory from all those years of dedication to excellence” to make his “miraculous” landing. (Air Evac declined a request to interview the pilot for this story.)

At the time, however, all that Abshire could think about as they settled into the muddy ground was the possibility of dynamic rollover. He desperately wanted out of the aircraft, and as he began the emergency shutdown procedure he screamed at Coupel to get out herself. “It made no sense for me to tell her to jump out of an aircraft with rotors still spinning,” he admitted. “But in that survival mode, it was just go, go, go.”

Coupel ignored him, remaining in her harness and exiting from the left side of the helicopter only after Abshire had completed his shutdown procedure: rolling down the throttle and turning the fuel and battery switches to OFF. In the time it took her to walk around the front of the aircraft, the pilot, still in an altered mental state, had managed to flip the switches back on.

She turned them off again, then physically pulled the pilot from his seat and stood between him and the aircraft as they waited for the emergency response. Abshire peeled himself backwards out of the cockpit and began attending to the patient — who, of course, was still on life support.

“As soon as we landed, it wasn’t five minutes before we had agencies from all over the place coming to make sure we were OK,” Abshire recalled. “9-1-1 had actually sent out that it was a helicopter crash, so everybody was coming.”

Coupel and Abshire had been working together for about a year before the event, and had “a great relationship,” Coupel said. That “mutual respect” formed the basis of their air medical resource management in flight.

Among the first to arrive was the ground ambulance team that had handed off the patient to begin with. They loaded up the pilot, and Coupel rode with him to Lafayette General. Meanwhile, Air Evac’s helicopter based in Opelousas, Louisiana, landed at the scene to intercept the patient, and also continued on to Lafayette General. (Today, the pilot is no longer flying, but has reportedly made a substantial physical recovery. Air Evac was unable to provide further details about the patient’s outcome for privacy reasons.)

Abshire learned later that the entire incident — from the time the pilot developed altered mental status until the skids touched the ground — lasted only eight minutes.

“You could never have convinced me of it,” he said. “It felt like three days.”

What now?

Back in O’Fallon, Air Evac’s leadership team was stunned by what had transpired. Within 36 hours, key managers were on the ground in Kinder, “just to give us hugs and make sure we were OK,” Abshire said. But it would take the company much longer to determine an organizational response to the incident.

“We had never dealt with anything like this, and there was really no playbook that was applicable for this type of event,” recalled Tom Baldwin. The first priority, he said, was to debrief the flight crew and OC specialist to understand exactly how the incident had played out from each of their perspectives. But that still left the problem of how to explain what had happened to the rest of the company’s employees.

“We had just had a sentinel event, it was a big deal, and we weren’t sure how to communicate this in the right way,” Baldwin said. “What we were worried about was getting there too early, and having flight crews come back and say, ‘Well, how are you going to protect me? How are you going to keep me safe if this happens to me?’ We didn’t have that answer.”

The leadership team considered the possibility that there was no answer — that perhaps pilot incapacitation was simply an inherent, unavoidable risk of single-pilot operations. But according to Baldwin, “none of us bought into that, none of us believed that. We said, there’s something we can do to give our flight teams a fighting chance if this were to ever happen again.”

Once they had developed a rough plan, Air Evac president Seth Myers recorded a video message to employees describing what had happened, and how they intended to prepare their teams to handle such events in the future. Over subsequent weeks, the company developed a training program in two parts.

The first part encompassed autopilot familiarization training for medical crewmembers: how to engage the HeliSAS, how to use it to hold heading and altitude, how to set it up to fly an approach to the nearest airport.

The simple two-axis autopilot in the HeliSAS won’t fly the aircraft all the way to touchdown, but it can take it close to the ground in a controlled runway environment, where fire rescue and emergency medical services can be standing by. The idea, said Baldwin, is to “go from a crash that is almost going to guarantee loss of life, to a hard landing.”

In addition to their in-depth training, Air Evac’s OC specialists now have this poster to reference when talking a crewmember through a pilot incapacitation event. Air Evac Photo

This video-based training has now been provided to all of Air Evac’s current nurses and paramedics, and has been integrated into initial training for new hires. According to Abshire, if he had had the training before his event, he would have known immediately how to tell that SAS and heading control were engaged. He would have known, too, that instead of counteracting the pilot on the sensitive cyclic control, he could have simply removed the pilot’s hand to have the HeliSAS auto-level the aircraft.

Most importantly, he said, knowing from the outset that there was something he could do would have instantly created the task orientation that is so critical in an emergency.

“When I got to the front of the aircraft, I was just going up there to fight, because I knew I wasn’t going to die sitting in a seat,” he recalled. “I didn’t have any idea what I was going to be doing.”

The second part of Air Evac’s training program was developed with and for its OC specialists, who now have clear, scripted guidance for talking crewmembers through a pilot incapacitation event.

“After the event, we felt we had dodged something there,” said OCC manager Brian Allison, a former U.S. Army Apache helicopter pilot who was a pilot recruiter for Air Evac before moving into his current role. OC specialists were given in-depth training on the HeliSAS system, then worked with the company’s flight simulator instructors to write and test the step-by-step procedure for responding to pilot incapacitation.

The procedure evolved through multiple iterations, but now “I feel we have perfected it,” Allison said. He noted that comm specialists with no flight experience have been talked through the procedure in the simulator with successful outcomes. And it’s not only medical incapacitation events where the procedure could be needed — it would also be relevant if a pilot were to be incapacitated by a bird or drone strike.

“It’s like practicing an autorotation or an engine-out procedure,” said Allison. “You may never ever see that, but when you do, you want to be ready.”

Working the problem

According to Baldwin, there’s no question that the autopilot technology on board the aircraft was vital to the successful outcome in Kinder. He emphasized, however, that another factor was just as important — Abshire and Coupel’s effective use of air medical resource management (AMRM).

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Coupel, center, and Abshire, right, pose with their program director, Corey Miller. Air Evac Photo

When Coupel first realized the gravity of their situation, she panicked. But as soon as Abshire tasked her with calling mayday, they were back on the same page, practicing what Baldwin identified as the fundamental principles of AMRM: communication, teamwork, and attention to detail.

“That would have been a very, very inefficient team had they not worked the problem together,” Baldwin said. “Had they not been able to do that, I’m not sure what the outcome would have been.”

Abshire has no doubt on the matter. “If it wasn’t for AMRM,” he said, “on that day, that incident does not go the same. We die on that day. If you don’t have that ability to communicate with your partner, if you don’t have that sense of trust between you and your partner, on a day like that, somebody’s just going to be sitting in a seat locked up, waiting for the inevitable.”

That professional rapport and personal friendship came into play weeks after the incident, too. Immediately after the event, Air Evac’s peer support team contacted Abshire and Coupel to offer their assistance. But as Coupel recalled, they were still riding an adrenaline high at the time. After all, they had survived the experience — why would they need help?

The true gravity of what they had been through didn’t strike home for them until weeks later, when, during their debriefing session, Air Evac’s senior leaders played the recording of Coupel’s radio calls.

“You can hear the pure fear in my voice,” said the Pierre Part, Louisiana, native. “You might not be able to understand anything I say because my accent’s so thick, but you know that I’m scared.”

After that, Coupel realized that she had been on edge lately, and hypersensitive to her surroundings. “Anytime somebody complained about this little inconvenience, I just wanted to snap and be like, ‘Yeah, well I almost died, so maybe you could just wait until your soup cools off before you burn your mouth on it. Just random stuff like that was so irritating.”

When Coupel confessed how she was feeling to Abshire, he said he felt the same way. So they sought help from Air Evac’s peer support group and contract psychologist, Tania Glenn, who helped them process their delayed stress response. “I was thankful for the fact that we both figured out we needed to take care of ourselves before we just let it go,” Coupel said.

Abshire reflected, “I think the whole mental side of our industry is something that people readily ignore, because we’re all Type As. And we’re used to: ‘Pick your head up, keep moving, you’re going to see bad things, you’re going to have bad days, but the tones are still going to drop, people are still going to be dying, and you’ve still got to go help.’

“So there’s no time to sit around and mope about our bad day, because we’ve got to keep going,” he continued. “And it just got to a point where we had to step back and realize, we can’t keep going, not like this.”

Since then, Abshire and Coupel have both joined Air Evac’s peer support team to offer help to other crewmembers coping with traumatic incidents. In October, they also shared their story at the 2018 Air Medical Transport Conference (AMTC) in Phoenix, Arizona. Abshire said he hopes that an event like the one he experienced never happens again. But if it does, he hopes the lessons learned will give another crew that fighting chance.

“Maybe it gives them the courage to not lock up in a seat and just die scared . . . to die fighting if that’s what’s going to happen,” he said. “I hope it at least gives them the courage to get up there and know that something can be done.”

SIDEBAR

Coping with a critical incident

The type of delayed stress response experienced by Tara Coupel and Lane Abshire is common among first responders, according to the trauma specialist who treated them, Tania Glenn.

Based in Austin, Texas, Glenn focuses on treating post-traumatic stress disorder (PTSD) and has devoted her career to serving veterans, first responders, and their families. She has contracts with Air Evac Lifeteam and several other helicopter air ambulance and airborne law enforcement operators to help their employees cope after critical incidents.

Glenn explained that a delayed stress response is one of two possible reactions to a traumatic event — the other being an acute stress response at the time of the event. Because first responders tend to be practiced at controlling their emotions under pressure, they may not experience the “fight or flight” symptoms of a stress response until a triggering event occurs weeks or months later. For Coupel and Abshire, that trigger was hearing the recording of Coupel’s radio calls and re-living the experience during the debriefing process.

“A lot of people are like, ‘I don’t know why this is happening now, because I’ve been fine,'” said Glenn. “What I explain to them is, ‘Hey, I know it’s not pleasant. But your brain is just telling you that it’s now ready to deal with it.'”

Glenn uses several different therapy modalities in her practice, including eye movement desensitization and reprocessing (EMDR). The goal of the therapy is to transform destabilizing trauma into more manageable “bad memories,” she said. “The difference between trauma and bad memories is, bad memories don’t trigger you and haunt you all day long, but traumas do.”

This is often combined with progressive desensitization. For flight crewmembers who have had a bad experience in the air, that may mean getting back in the helicopter with Glenn for a confidence-building flight.

Glenn said that recognizing and treating the symptoms of a stress response early, as Coupel and Abshire did, can be extremely effective in preventing progression to PTSD. Peer support teams like Air Evac’s can be very helpful in this respect, by alerting their colleagues to symptoms to watch for and encouraging them to seek treatment when they need it.

“It really facilitates trust and confidence, and a willingness to sit down with a shrink, which isn’t hugely popular,” she said. “A lot of people who have had peer support in the aftermath of an incident will say, ‘I don’t know how I could have done this without this team.'”

However, if you’re struggling with symptoms of trauma, the absence of a peer support team shouldn’t stop you from seeking help on your own — and Glenn emphasized that it’s never too late. She recommends seeking out a therapist who specializes in trauma and PTSD; apart from that, she said, the key is to find someone with whom you feel comfortable on a personal level.

“You may have to educate your therapist on aviation, and flight, and what all that means. But it’s worth it to do that groundwork if you get in with someone you trust,” she said.

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