Four meetings were held in 2010. In addition some members flew to France to join our French counterparts there.
Spring Meeting: Saturday 27th February 2010, London.
Venue: Royal College of General Practitioners.
Theme: Teamwork in the Aviation Environment: The flip side of the flight plan.
Our February programme, largely put together by Dr Claire McCready, was worthy of an international audience. She has assembled an exciting team of speakers who have agreed to give up their leisure time at a weekend. They provided us with a stimulating mixture of education and entertainment.
|Chairman: Dr Andrew Clymo
|Registration and coffee
|President’s welcome and opening remarks
|Dr Elizabeth Wilkinson, British Airways Health Services
|Aircrew – what makes a good pilot?
|Sqn Ldr (Retd) Art Stacey AFC
|Ditching the Mighty Hunter – a personal account
|Prof Mike Bagshaw, Cranfield
|Human factors training for aircrew – have we got it right?
|Sqn Ldr Damien Carapiett
|Taking ‘Forward Aeromed’ forward – evolution of the Medical Emergency Response Team (MERT)
|Chairman: Dr Claire McCready
|Sqn Ldr Gus Cabre, RAF CAM, Henlow
|Analysis of the first aviation accident – why did Icarus really die?
|Capt Neil Jeffers and Dr Mark Wilson, Neurosurgeon
|Operational co-operation in a Helicopter Emergency Medical Service
|Sqn Ldr Graham Duff, Flt Lt Zane Sennett, The Royal Air Force Aerobatic Team ‘The Red Arrows’
|The demands of professional display flying
|Discussion continued in RCGP common room
|Dinner in the Long room, RCGP
Report by Peter Anderson.
The meeting was opened by President Andrew Clymo, who welcomed us all, but unfortunately had to report the death of founder member Dr. John Davidson, General Practitioner and Osteopath. The meeting stood in his memory.
The four morning lectures were chaired by Andrew Clymo, and following a good lunch, Claire McCready wielded the baton for the three afternoon lectures.
All lectures were well delivered and most interesting, and our many questions were answered enthusiastically.
After the lectures, there was the usual double blind assessment of bar facilities, followed by an excellent Association Dinner, a credit to the catering staff, who were thanked on our behalf by President Clymo.
Lecture 1: Aircrew – what makes a good pilot? – Dr Elizabeth Wilkinson, British Airways Health Service.
After noting that the media can take an unhealthy interest in pilots’ misfortunes, she reminded us that the good airline pilot must cope with mundane routine, but be able to promptly respond to sudden challenge from the unforeseen. Recent examples included landing an ailing Boeing 777 at Heathrow, writing off the hull, but no serious passenger injuries, and landing a sick Airbus on the Hudson River, both shining examples of pilot competence.
She outlined for us the selection process, medical assessment both initial and revalidation, and possible direction of future screening.
An airline pilot clearly needs many technical skills, but also must have various other skills, e.g., team working and leadership, CRM knowledge, business based assessment (diversions, offloading), ability to travel overseas, act as “doctor” (? divert), and oversee security.
The aim of the medical examination is to determine fitness for role, and includes history, examination, and functional check of physical and mental states. Risk assessment concerning sudden incapacitation is clearly vital, for example with reference to heart attacks, stroke and hypoglycaemia.
The “one per-cent” still applies in that there should not be more than 1% chance of incapacity per two pilot operation in the validity period of the certificate. An unrestricted Class One medical implies approximately a less than 0.1% risk. A greater, but acceptable (1%) risk will carry an OML (Operational Multicrew Limitation), i.e. must fly with an unrestricted colleague.
The initial Class one is at the CAA, thereafter regular revalidations are with an AME. The “Rules” were originally CAA, latterly other bodies, and the EASA view is awaited. Airline specific issues can involve career pathways, training cost, loss of licence and related pension factors, overseas travel, irregular hours and effect on family life.
Historically BA did an extensive medical with many tests, but partly due to the Disability Discrimination Act of 2004, tests are much reduced, and paper questionnaires more used. Under age 40, physical disease is rare, but alcohol, drugs, anxiety and depression feature more. Early diagnosis leads to improved outcomes. In 2009, of 3,500 crew, long term unfitness totalled 14, half psychiatric, half physical but none cardiac.
Future screening is likely to concentrate on behavioural issues. Physical disorder is uncommon in the young. The last public transport accident world wide caused by cardiovascular factors was over 20 years ago.
In the future, long term health of pilots and health education will need to assess life style and family concerns. Current issues question the emphasis on physical disease and the value of the 1% rule: are we losing experienced pilots unnecessarily?
Lecture 2: Ditching the mighty hunter – Squadron Leader Art Stacey AFC RAF
Art Stacey, who has nearly 10,000 hours in his log books, reminded us that one origin of the word “Nimrod” was from a hunter in Greek mythology, thus fitting well these wonderful aircraft whose purpose is to hunt undesirables hiding from us. On May 16th 1995, 51 Squadron had three specially fitted out “hush hush” Nimrods, one of which required a post major servicing air test. These three were numbered 664, 665, and 666, which numbers add up to 51, the same as the Squadron designator!
On a planned four hour test flight, with full crew, the brief was to test all functions, work enough for him, but pity the flight engineer! Half an hour into the flight, an orange warning light came on, indicating an electrical fault. They decided to dump fuel and return to Kinloss, but very soon came a fire warning from zone 1 of the number four engine, the cool (!) front end. The Rolls- Royce Spey engines had a good record, with no engine fires, in twenty five years. The crew behind could see the fire, and throughout gave succinct reports to those up front. The fire persisted despite using the two extinguishers, and another two from the adjacent engine. The only other immediate indication was that the aircraft shuddered for about half a second.
Sq. Ldr. Stacey reminded us that “accidents” are usually the end result of a chain of events. Around twenty years before an engineer had expressed doubts about the adequacy of a nut in the starter unit. Though the manufacturer denied any problem, the RAF insisted on a better nut, but not all aircraft were modified.
This day, two wires had frayed and short-circuited, giving the initial orange warning light, and causing the starter motor to spin up to 100,000 + revs per minute in a very short time. The unmodified nut broke, the motor disintegrated, and bits of starter turbine blades penetrated a fuel tank, causing fire. Luckily the tank was full, had it been near empty there would have been an explosion of the vapour, with much greater initial damage. Number three engine then indicted a fire, so was shut down.
Going home was clearly the best option. Kinloss was visible forty miles away on this clear, calm day, but Lossiemouth was ten miles nearer, so they set off towards Lossie, going down to 1,000 feet at 300 knots. The flaps were unusable, aileron effect suspect, and the crew behind thought the wing was melting. (Later inspection revealed that perhaps as little as 30 seconds were left before the main spar broke.) He decided to ditch, considering now that Lossie was too far away. The calm surface was difficult to judge, but he touched at 127 knots, with two bounces. Though there were some injuries, all the crew got into a dinghy, and a nearby rescue helicopter carried out a very efficient rescue. They were unimpressed with the treatment at the local hospital, and were glad to be transferred to RAF Halton medical services.
He reckoned the day out cost £83 million pounds: £40m for the loss, £40m for a new one and £3m for the Navy to recover the bits for inspection.
Lecture 3: Human factors training for aircrew – have we got it right? – Professor Michael Bagshaw
Around twenty years ago, Ron Campbell and Michael Bagshaw became increasingly concerned about GA accidents caused by human error. In 1991 they published a book about Judgment and Decision Making, and soon after the CAA had similar ideas, introducing an exam on “Human Performance and Limitations” in 1992. The book was re-titled appropriately, the third edition being in 2002. A new edition is on the way, with input from Prof. Helen Muir, Ron Campbell having died in 1996.
Most accidents have a significant human error factor, and the question arises, does a “tick box” exam produce any real benefit? Does knowing the alveolar partial pressure of oxygen at FL220 help your average 152 pilot? Year on year statistics are of limited value since there is no reference to hours flown.
Accident causes remain familiar – weather beyond capability, short runways, obstacles, fuel exhaustion, drugs or alcohol effects, loss of control including stall/spin. Many feel that taking spin awareness and actual spinning from the PPL course was wrong.
Human error will always occur, including in flight crew, but they cannot always break an event chain arising anywhere, e.g. design, maintenance, fuelling, you name it! Tick box exams can become a soon forgotten “learnt for the test only” step on the trudge to the licence.
“Wellbeing” is very important, being a resultant of physical, psychological and emotional factors interacting. A less obvious, but important factor might be an “invisible shell” of personal background problems distorting the picture.
Prof. Bagshaw used the Yerkes – Dodson “Bell Curve” to illustrate the relationship between Arousal (horizontal axis) and Performance (vertical axis), demonstrating that a fair level of arousal is needed for decent performance. Too little or too much of A gives poor P.
Arousal is a compound of wellbeing, stress, mental overload or underload (long haul?), personality, task difficulty, extroversion (needs noise etc), and introversion (easily aroused).
Stress is a non-specific response to demands. Pressure is not the same, that gets us moving, but too much of it can cause stress, which itself can result from, for example, the environment, life problems, reaction to problems, or organisational issues. The response to stress can be both physical and psychological, and for this we will have a certain capacity, not to be confused with aptitude (skills).
A useful analogy is a bucket with an overflow outlet on the side. At some point the ingoing water (stress) will overflow, leaving problems unsolved. This can lead to errors, e.g., omission (wheels up?), bad prioritisation, filtering of stimuli (not hearing the radio), coning of attention, regression to type, or escape (all too much, want Mummy). Fight or flight (so to speak!). We process our information (sensory input) through our “gate”, and on a good day some useful motor action comes out.
Judgment and decision making need two sources. First, Perceptual Input, such as assessment of speed, distance, obstacle clearance, closure rate, etc, and second, Cognitive Input, i.e., attitude to risk, derived from personality, and evaluation derived from knowledge, skills and experience.
Prof. Bagshaw told the remarkable Blackpool Cherokee story, which illustrated the consequences of a whole collection of human errors resulting in two dead in the sea. They went to Exeter, an inexperienced commander out of the 90 day currency rule, an out of practice companion, no refuelling or weather update at Exeter, illegally into IMC on the way back, in a VMC only equipped aeroplane, Blackpool fogged in, altimeter five millibars out (indicating higher than actual), insufficient fuel for a diversion to CAVOK Leeds, twenty minutes away.
Airmanship requires judgement. You can teach skills and knowledge. HP&L may help with judgment, systematic problem solving and awareness of false hypotheses and expectancy.
Lecture 4: Evolution of the medical emergency response team (MERT) – Squadron Leader Damien van Carrapiett
Damien van Carrapiett is a very English gentleman with Dutch ancestry. He has a background of Accident and Emergency nursing, and is widely experienced in military medical matters. He is the acting C.O. of the Tactical Medical Wing, the aim of which is to facilitate prompt transfer of casualties from the battle area to a UK hospital. “Forward Aeromed” is the section dedicated to getting the casualty from battle area to the first “hospital” environment.
He gave us a brief historical review: Napoleonic times, tough! ; WW1, with field hospital, average twenty hours; WW2,ten hours: Korea and Vietnam, with helicopters, about thirty minutes; Dhofar (late 1960s), dedicated six stretcher helicopter and medical officer; Falklands, nothing dedicated, all ad hoc, could be twenty-four hours. Modern operations, e.g. “Telic” (Iraq),and Herrick (Afghanistan)are much complicated by counter-insurgency, there being no defined battle area, and ground transport security is difficult.
The aim of MERT (Medical Emergency Response Team) is to bring “Emergency Room” elements quickly to the battle space, since over 90% of seriously wounded can die in the first hour. MERT has a dedicated helicopter and team of Anaesthetist, Medical Officer, RAF Emergency Nurse and two RAF paramedics.
They work to a pattern called ” 1:2:4 “, which means, in the first hour, advanced first aid, in the second hour rescue, and by the fourth hour, definitive treatment. The immediate aims are : advanced airway management, control of hypotension (blood), antibiotics, analgesia and prevention of hypothermia.
There are many practical difficulties:- communications are difficult, planning, of necessity is hurried, and the environment is very hostile. The equipment must be useable in a Chinook, where the noise, vibration and poor lighting are problematic. The team has difficult decisions to make in deciding who to treat and roles, responsibilities and rank need careful integration. On one occasion twenty six casualties were lifted from a remote hostile site in six minutes, with no deterioration in flight.
However, MERT is a small scale operation in the larger pattern of things, with high value resources, being the dedicated helicopter, and doctors and nurses.
For further reading on this subject, Sq. Ldr. Van Carrapiett strongly recommended the book “MEDIC”, by John Nicol and Tony Rennell (IBSN 978-0-670-91604-7)
Lecture 5: The first aviation accident – why did Icarus really die? – Wing Commander Gus Cabré
Gus Cabré, a Barcelona graduate, has been in Surgery, General Practice, and now Aviation Medicine in the Royal Air Force. He is a keen flyer and has pulled all the RAF flying clubs into an integrated association. He took us most cleverly through a mini-course in human error and basic physiology, disguised as an analysis of the downfall (!!) of Icarus, the well known aviator of Greek Mythology.
First, a little background history. Around 1325 BC, King Minos of Crete was fuelled with anger as his wife Pasiphaë had had an affair with a white bull, producing a bull headed humanoid called Minotaur. This odd character had to be kept secret in a labyrinth, built by the artificer Daedalus. Kingy then imprisoned Daedalus and son Icarus so that they could not talk too much about wifey’s exploits. D & I were much miffed, so D made some wings with feathers and wax, and off they set. It is said that D made it to Sicily, but myth has I. ignoring Daddy’s advice, flying too high, so that his wing wax melted and down he went, becoming severely drowned.
Our raconteur was not convinced for several reasons. Firstly, the Sun is 93 million (give or take 2 million), miles away and it gets colder as one goes up. So the melting theory was rejected and he considered various other possibilities, including many with Human Factor elements. He presented “graphic evidence” from old times to hypothesize what really happened.
The chances of being shot down or suffering a bird strike were rapidly dismissed. Did he climb well above 10,000′? His alveolar pO2 would have gone down, causing his time of useful consciousness (TUC) to run out, suffering therefore from altitude incompetence or even hypoxic death. Maybe, with the lack of IMC training, he flew into cloud and his inner ears would have given him all sorts of inaccurate information, thus rendering the receptors in the seat of his pants (in this case, the sleeves of his arms) useless. This may have been aggravated by a little alcohol as he celebrated the escape with father just prior to departing. Maybe he was caught in a lively CB which shook him and on trying to regain the right attitude he pulled too hard to the extent of suffering from G (gravity) consequences like grey out, blackout and eventually G-LOC (Loss of Consciousness). All this could have been compounded by other factors such as stress or fatigue.
On balance, Gus reckoned that he climbed too high and became hypoxic suffering in cloud from vestibular illusions; he lost control of his movements, dived, pulled too hard and off came his wings. But, then again, this is a myth after all and it has been suggested that the jilted daughter of one of the Gods came along and cleverly cut off his wings. A thinking man in the audience wondered whether his wings would have been the prime target if he had been playing away!
Gus gave a perceptive and most humorous dissertation on the causes of accidents. A summary hardly does it justice.
Lecture 6: Operational co-operation – helicopter emergency medical service – Captain Neil Jeffers and Dr. Mark Wilson, Neurosurgical Specialist Registrar
The helicopter Emergency Medical Service (HEMS) is an extension of the London Ambulance Service, which gets 3-4,000 calls per day. The HEMS helicopter does four or five runs per day, being available from 0800 – 1845 or sunset every day of the year, and has done 22,000+ sorties since the start in 1988.
It is based on the roof of The Royal London Hospital, five floors now, but will be the highest hospital in Europe with eighteen floors when rebuilt. The helicopter can reach anywhere within the M25 within around ten minutes. There is also a car available. The team consists of two pilots, a doctor, paramedics, fire crew for take off and landing, data/research/fundraising management, and rapid response vehicle manager. The command gradient was discussed, reminding us of the first officer who was too nervous to mention a low approach to a bad tempered captain. After the crash, the autopsy showed that the captain had been dead for ten minutes prior to impact! This team works well together, and recognises that the paramedics are often the best judges of a bad situation. Personal equipment comprises an orange flameproof suit, hard hat, steel capped boots, stab proof vest and goggles. The aircraft/car kit is checked daily, so that all know where everything is.
The helicopter is a MD902 Explorer, rated for single pilot IFR flight. It is safe, quiet, has an excellent power to weight ratio, is large inside but not too big outside. There is no tail rotor, it uses vectored thrust instead, with downwash over the tail boom providing much of the required anti-torque force. Instrumentation is pictorial rather than dials, and some displays only show if parameters are exceeded.
The day starts with morning equipment checks at 0630. Then comes the daily briefing – weather, notams, fire cover check, road and bridge closures, drugs and refrigerator check, and some “scenario training” on a battered manikin.
Matching resources (HEMS) to demand (RTAs etc) can be difficult. From call to being airborne takes three minute or less, the second pilot dealing with communications, which are kept from the pilot flying, so as not to encourage ‘red mist’. The call sign “Helimed 27A” gives airspace priority, and weather minima are 300 feet and two kilometres, though so little is rarely used. Landing sites can be almost anywhere, providing a square of twice diameter is found, being about eighty feet square. flashing lights and sirens help to clear traffic. On the ground, to avoid conflict, the team tries to involve police, ambulance, etc. Standardised reporting avoids confusion – Situation, Background, Assessment, Recommendation.
Medically, airway maintenance is vital, and intubation can involve several people if position, space and access are difficult. A surprising number of procedures can be done if needed. On handover at the hospital, again standardised reporting is used.
Finances – about £1.7 million per annum, 870K from the NHS and 200K from Virgin, the rest from charity sources.
Lecture 7: The Red Arrows – The Demands of Professional Display Flying – Squadron Leader Graham Duff & Flight Lieutenant Zane Sennett
Graham Duff, now in his third year, explained that the Red Arrows act as ambassadors for the UK, promote the work of the RAF, encourage recruitment , and are involved in defence diplomacy and our overseas interests. Fifty years ago all squadrons had a display teams, but gradually the present team of nine Hawks has evolved, with a spare aircraft flown by “Red 10″, who is the display commentator. If a pilot is indisposed, the team fly with a blank space.
The whole team, including engineers, management and photographers totals around 120. All sorties are filmed, and viewed critically before the next outing. The engineers (” The Blues”) are dedicated to each pilot and machine and travel rear seat between events. All pilots have at least 1.500 hours on fast jets and have done front line work. A “Reds” tour is three years, though the leader can do six. Selection from applicants is whittled to nine, and the election of the next three, after formal interview and flying tests, is done by the team behind closed doors. This year the first lady pilot for the Reds, Flt. Lt. Kirsty Moore, has joined.
For the first year the new entrants fly next to the leader, moving later to the more difficult distant positions. The Hawk is a tandem two-sweater, with Mach 1.2, 48,000 feet, 1,000nm capability. The coloured smoke is produced by injecting diesel fuel, with dyes, into the jet exhaust, released by buttons on the stick. The possibility of pressing the wrong one is a source of anxiety! There is five minutes of white smoke, and one minute each of red and blue, and the total smoke cost per outing is a surprising £4,000. They fly normally six to ten feet apart, lining up on the tail and wing root of the adjacent aircraft, and control is by voice from the leader.
Zane Sennett, starting his second year, explained that it was very different to operational flying. The year runs from October to October, being training to the end of May, then five months of display flying. A very measured “building block” approach is used in training, newcomers spending a bespoke two week period with the “boss”, gradually building up the numbers to the full nine aircraft. All rolls are to the left, a practical approach to the intricacy of seven aircraft rolling precisely as if joined together.
Each training session is around thirty minutes of intense physical and mental effort, and the debrief, with analysis of a film of the outing, is very thorough. The best one to note a filmed fault is the one who did it! “Good enough” is not good enough, perfection is the aim. Three sessions a day, five days a week! By Thursday they are feeling a bit worn.
A display lasts 22 minutes, ideal for pilots and crowd. There are three weather options: Full (6,000 feet) : Rolling (2,500 feet) : and Flat (1,000 feet). The Reds are the only display team in the world capable of altering the type in mid–display.
A display has two elements. First, all nine aircraft together, and then the aircraft in two sections, one arriving as the other leaves the area. Transiting between displays, they can do flypasts of ground events. One nerve-racking non-standard item was formating on a Virgin 747, they were not happy with the 747 wings flapping up and down!
Up to three displays a day are done, with typically ninety minutes on the ground between, for debrief, aircraft servicing, and remembering the important food and drink, easily forgotten.
In addition to the heavy flying workload, there in a substantial amount of non-flying work, to do with PR presentations, industrial work for BAe and Rolls Royce, charity visits, supporting their local helpers, and generally showing the best of Britain to the world. Few, if any, of us had any idea of how hard these exceptional people work. We were most impressed.
Spring Outing: 1st April 2010.
An extra meeting this year was a tour of Prince Charles’ garden at Highgrove House, Tetbury, Gloucestershire, organised by David Hillam. Although too early in the season to see much colour, our garden enthusiasts were impressed by the garden design and the detailed input by Prince Charles himself.
Rassemblement International Médecins-Pilotes, 10th-13th June, Royan, France.
Several members of the BMPA enjoyed the fly-out and meeting with our French counterparts and received wonderful hospitality. Visits included L’Arsenal Maritime in Rochefort, the Old College of Naval Medicine, shipyards, ropeworks and the lighthouse of Cordouan in the Gironde estuary, the oldest lighthouse in Europe (which involved paddling ashore from a zodiac).
Summer Meeting: 26th-27th June 2010, Shenington.
The usual gliding weekend took place and members enjoyed some gliding in a relaxed and friendly atmosphere.
Autumn Meeting: 10th-12th September 2010, Hitchin, Hertfordshire.
Our base for this meeting was Letchworth Hall Hotel, Hitchin, Hertfordshire. Visits included the Shuttleworth Collection at Old Warden and the de Havilland Heritage Centre at Colney Hatch.