Today’s drug shortage update from the FDA (Food and Drug Administration) includes a lot of drugs that used to be routine drugs for cardiac arrest.

Once upon a time, I was a code drug.

Atropine is the most recent drug to be dumped by the AHA (American Heart Association). In the past week, two manufacturers have stated that they have atropine available. FDA Update.

It was nice to see the AHA admit that there is not a good reason to keep treating every PEA (Pulseless Electrical Activity) or asystole patient with a drug that has never had good evidence that it improves survival. The next revision of the ACLS (Advanced Cardiac Life Support) guidelines will provide more opportunity to get rid of some drugs that are routinely used for cardiac arrest, even though there is no evidence that they improve survival – lidocaine (farther down on this list), amiodarone, and the everybody’s favorite drug to not improve survival – epinephrine (also farther down on the list).

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Calcium Chloride has increased availability from one manufacturer, but decreased availability from another. Calcium is still the best drug for hyperkalemia, but it was once used routinely in cardiac arrest, as if there has been a lot of sudden onset hypocalcemia. FDA Update.

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Epinephrine 1:10,000 has not yet been dumped by the FDA, but the recent evidence suggests that we are decreasing survival by using epinephrine – and those who do survive the epinephrine are more likely to have significant brain damage. FDA Update

Tomorrow, I will be talking about the evidence for and against epinephrine at the EMS Web Summit.

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Lidocaine has new manufacturing delays. Lidocaine is still just barely in the ACLS guidelines –

Amiodarone may be considered when VF/VT is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb, LOE A). If amiodarone is unavailable, lidocaine may be considered, but in clinical studies lidocaine has not been demonstrated to improve rates of ROSC and hospital admission compared with amiodarone (Class IIb, LOE B).^[1]

Maybe lidocaine is there to make amiodarone look good, because nothing else makes amiodarone look good.

For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.^128,–,133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.^{31,33,134,–,138 [2]}

In other words, these drugs are probably only as effective as atropine, and maybe less harmful than atropine, but the AHA has not given up on them, yet. FDA Update.

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Magnesium Sulfate is another once-promising code drug, now used for the ever-impressive torsades and for the less impressive hypomagnesemia. FDA Update

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Sodium Bicarbonate used to be given almost as much as epinephrine.

Now, Sodium Bicarbonate is only given when it is specifically indicated – the way that real medicine should be used.

Sodium Bicarbonate is second line for hyperkalemia and probably is just the hypertonic saline (5.8% saline) that is working, rather than treatment of acidosis, but acidotic patients may benefit from that, too – if they are well ventilated. Sodium Bicarbonate is CO₂ in a syringe.

FDA Update.

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Vasopressin is now available, again. Not useful in cardiac arrest, but we feel we need to inject something, so this permits some variety. FDA Update.

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Important non-code EMS drugs on the FDA Current Drug Shortages list are:

Alfentanyl – Possibly substituting for fentanyl, but not having enough to make up for the lack of fentanyl. Probably also due to increased realization that the side effects of opioids are easily managed by competent medical personnel.

Atracurium (Tracrium).

Diazepam (Valium).

Digoxin.

Diltiazem (Cardizem).

Diphenhydramine (Benadryl).

Etomidate (Amidate).

Fentanyl (Sublimaze).

Hydromorphone (Dilaudid).

Ketorolac (Toradol).

Lorazepam (Ativan).

Mannitol.

Metoclopramide (Reglan).

Midazolam (Versed).

Morphine.

Multi-vitamin injection (banana bags?).

Naloxone (Narcan).

Naltrexone.

Ondansetron (Zofran).

Oxytocin (Pitocin).

Pancuronium (Pavulon).

Phentolamine (Regitine).

Procainamide (Pronestyl) – the only ventricular antiarrhythmic that works (of those commonly available in the US – [sotalol also works]).

Prochlorperazine (Compazine).

Promethazine (Phenergan)

Propofol (Diprivan).

Sufentanyl (Sufenta).

Tromethamine (Tham).

Vecuronium (Norcuron).

and something new –

Sodium Chloride 0.9% (5.8mL and 20mL) (Initial Posting Date) – 5/4/2012. FDA Update.

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Footnotes:

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^[1] Drug Therapy in VF/Pulseless VT
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Advanced Life Support
Part 8.2: Management of Cardiac Arrest
Free Full Text from Circulation

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^[2] Overview
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Advanced Life Support
Part 8.2: Management of Cardiac Arrest
Free Full Text from Circulation

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JPM (JPMorgan Chase & Co.) has reported to shareholders that they had a loss of $2 billion on a hedge that didn’t work.

A hedge?

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The FBI joins the Federal Reserve, the Securities and Exchange Commission and regulators in Britain in investigating the loss on trades meant to help protect JPMorgan against credit risk. Instead, the complex trades backfired, causing a huge hit to the bank’s bottom line and its reputation.^[1]

The more complex things are, the more things that can go wrong. A contraption that is as complicated as a Rube Goldberg design is probably not going to increase safety. All it takes is an unforeseen change in one part to alter the results from success to embarrassment.

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Image credit.

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Treasury Secretary Timothy F. Geithner on Tuesday called the loss a “failure of risk management.”^[1]

Without enough oxygen, we will die. The loss is “failure of risk management.” These statements are correct, but they do not tell us anything we do not already know. Who loses a couple of billion dollars without some sort of failure of risk management?

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The ability of JPMorgan and the financial system to withstand the loss showed that reforms put in place after the 2008 financial crisis have worked, particularly the requirement for banks to hold more cash in reserve, Geithner said during an appearance at the Peter G. Peterson Foundation’s 2012 Fiscal Summit.^[1]

Really?

Would this have caused JPM to fail if this had happened in 2007?

Based on what?

What if JPM put more money into this hedge out of a false sense of security provided by these new regulations?

Or is this just another example of the banks doing the same thing we do in EMS?

We often misunderstand the risks we take.

The magic phone call to medical command for permission to give a treatment is a perfect example of misunderstanding risk. This requirement encourages medical directors to authorize dangerous paramedics to treat patients out of the mistaken belief that They have to call to do anything dangerous. As if dangerous people are limited in the ways they can be dangerous.

Or the paramedics who just want to know how to avoid getting in trouble. They aren’t concerned for the patient. They are more interested in creating an alibi. How can I avoid responsibility? Is this the way to provide good patient care.

JPM appears to have misunderstood the risks they were taking. The guy at the top is at least giving the appearance of taking responsibility, rather than making an announcement that The usual scapegoats have been fired, so that the management does not have to accept responsibility or make any substantial changes.

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As media reports surfaced about the chief investment office in early April, Jamie Dimon, the bank’s chief executive, publicly played down the concerns, calling them a “complete tempest in a teapot.”

After Mr. Dimon and other senior executive learned more, he sounded a more contrite tone. On Thursday, when disclosing the loss in a conference call with analysts, Mr. Dimon acknowledged that the bank had made “egregious mistakes.^[2]

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J.P. Morgan’s Chief Executive James Dimon told convened shareholders the trades leading to billions in losses at the bank were “flawed, complex, poorly conceived, poorly vetted and poorly executed.”^[3]

“This should never have happened,” Dimon said at the meeting. “I can’t justify it. Unfortunately, these mistakes were self-inflicted.”^[3]

J.P. Morgan’s losses have raised questions about the need for greater regulatory oversight and the bank’s stance on financial reform. Dimon said the bank supported “70% to 80%” of the Dodd-Frank financial-reform law and is “not against new regulations.”

“We do continue to believe in the importance of being able to hedge risk as an institution,” he said. “However, we also understand the need for rules and practices to ensure that hedging doesn’t morph into something different. What this hedge morphed into violates our own principles.”^[3]

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Footnotes:

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^[1] FBI opens inquiry into JPMorgan Chase $2 billion trading loss
By Richard A. Serrano and Jim Puzzanghera
May 15, 2012, 10:20 a.m.
LA Times
Article

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^[2] F.B.I. Begins Preliminary Inquiry Into JPMorgan
May 15, 2012, 12:37 PM
Legal/Regulatory
by Ben Protess
NY Times DealBook
Article

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^[3] 2nd UPDATE: JP Morgan’s Dimon: Hedge ‘Should Never Have Happened’
May 15, 2012, 1:15 p.m. ET
By Erik Holm and Christian Berthelsen
Wall Street Journal
Article

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Don’t click on the images. They will only take you to larger versions of the same image. Click on the link right below this sentence.

Link to EMS Web Summit home page.

I am reposting this with a few changes and as a reminder that this will be in two days.

The EMS Web Summit is free and you will be able to ask questions of the presenters. Kelly Grayson’s presentation is “Granny Has a Fever” (I did not know what the topic would be when I wrote the original post). Rommie Duckworth’s presentations look as if they are going to be in the opposite order from what I originally wrote (200pm – 230pm and 330pm – 400pm). As Rommie Duckworth wrote in answer to a comment to the original post –

1) All times are EST

Time Zone Converter.

2) Presentations are live.

3) The availablility is worldwide.

4) There is no need for a webcam to participate.

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Sign up. Participate. Enjoy.

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Everything is being coordinated by Jim Hoffman of EMS Office Hours and EMS SEO. Thank you, Jim.

Jim states, Come join all sessions or just a few. This is live so feel free to come and go as you like.

Here are the topics and speakers listed on the EMS Web Summit site. Times are Eastern Daylight Time (The time zone of New York City or Coordinated Universal Time minus 4 hours).

Time Zone Converter.

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1000am – 1015am – Jim Hoffman will open the day with some brief commentary.

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1015am – 1045am – What You Don’t Know, Might Hurt Them!
Bob Page, BAS, NREMT-P, CCEMT-P, NCEE

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11am – 1130am – Use Social Media to Market Your EMS Agency
Greg Friese, MS, NREMT-P of Everyday EMS Tips and Medical Author Chat.

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1145am – 1215pm – The EMS Mentor
Dan Limmer

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1230pm – 100pm – How to Earn Your Flight Crew Wings
Troy Shaffer, BS, ATP, CFII

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115pm – 145pm – Say This, Not That | Critical Elements Of Patient Rapport
Steve Whitehead, NREMT-P of The EMT Spot.

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200pm – 230pm – The Silent Majority: Geriatrics in the New Millennium
Rommie L. Duckworth, LP
This and the 330pm – 400pm may be switched. I don’t know which presentation will come first.

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245pm – 315pm – Abandon The Ambulance This Is EMS In Remote Areas
Jamie Todd BSc (Hons) | Clinical Lecturer / Paramedic Practitioner

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330pm – 400pm – Belly Busters: Abominable Abdominal Trauma
Rommie L. Duckworth, LP
See my 2pm – 230pm comment.

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415pm – 445pm – Can Patients Survive Epinephrine After ROSC?
Me –

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As if anyone who has been reading this blog over the past month would have any doubt if I would cover that topic.

I will try to write about some more research on epinephrine in the next few weeks.

I usually cover just one paper at a time, but I am looking at the EMS Web Summit as a presentation to try to scan through all of the epinephrine in cardiac arrest research and put it into perspective.

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500pm – 530pm – Dazed and Confused
Evan Feuer , BA, NREMT-P

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545pm – 615pm – Granny Has A Fever
Kelly Grayson (A Day in the Life of an Ambulance Driver) no topic, yet. Don’t let that worry you, because Kelly can speak on any topic and make education both entertaining and informative.

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630pm – 700pm – Crafting Content for EMS Agencies
Dave Konig – The man behind EMS Blogs and The Social Medic. He is also sponsoring the EMS Web Summit. Thank you, Dave.

EMS Blogs is the host site for all of the blogs on the upper right of the sidebar.

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715pm – 745pm – EMS Changes
Peter Canning (Street Watch: Notes of a Paramedic). Peter is counting down My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic. He will probably finish just in time for the EMS Web Summit. He always has an interesting perspective on the way we provide care to patients,

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800pm – 830pm – Cardiac Arrest Management Updates for the EMS Provider
Sean Kivlehan, MD, MPH, NREMT-P

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Times are Eastern Daylight Time (The time zone of New York City or Coordinated Universal Time minus 4 hours).

Time Zone Converter.

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The sponsors are giving away a variety of EMS Tools and Resources. Check out the sponsors and their gifts below.

WANTYNU.com – Josh is giving away two of his O2 wrenches each hour

StatGearTools.com is giving away 5 tape holders, 5 laryngoscope bottle openers, 5 EMS bottle openers and 2 of their new Triage tools

TalonRescue.com is giving away 3 of their new Treck Multi Tool

Centrelearn.com is giving away an annual subscription to one BLS and one ALS level online CEU courses.

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You do not have to attend the whole day of courses.

You should try to attend at least one section to see how it works. I think you will want to stay for more.

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This QR code links to the EMS Web Summit home page.

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Part I was written in 2010, so I am a bit late in continuing to ridicule this example of bad research.

How do we determine what is good care for our patients?

By having our treatment follow the category that dispatch dispatch assigned the call? I used to work in a county, where this did appear to be the case. The medics would become very upset with dispatch if they did not receive a lot of information about the patient prior to arriving on scene.

Dispatchers would express surprise when I would tell them that I did not care about the information they could obtain over the telephone from some unknown person.

Why?

Apparently, these medics never learned to assess patients themselves.

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We conducted a population-based retrospective cohort study of 800 randomly selected patients over the age of 30 years for whom EMS were dispatched for a complaint of chest pain during a single year.^[1]

These are not patients with a medical complaint of chest pain, but patients dispatched as chest pain – for whatever reason.

These are not patients considered to be cardiac by the emergency physician, but patients dispatched as chest pain.
 

The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured.^[1]

Should we give aspirin (as a cardiac treatment) to patients who do not have, and never did have, chest pain?

Should we give nitroglycerin (as a cardiac treatment) to patients who do not have, and never did have, chest pain?

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The role of dispatch is not to determine the treatment for the paramedics or for the physicians. The role of dispatch is to prioritize getting the right people to the patient in the right amount of time.

What information do I want from dispatch?

How many patients they believe are there.

Trauma vs medical.

Reports of any violence or anything suspicious of violence.

Who else is responding.

Any reports of traffic problems in the area, or other unusual events that might affect what we do.

Unusual (or amusing) things picked up during the phone call.

The location of the patient.

Should there be any more of an exchange of information than the following?

Respond to location X for an adult with chest pain. X is also responding.

10-4.

Dispatch has more important things to do than to do assessments for incompetent medics.

According to the authors of the study, if dispatch mentions chest pain, I am supposed to follow my Suspected ACS (Acute Coronary Syndrome) protocol, even though that protocol does not mention anything about receiving medical direction from dispatch. The protocol begins with the words, Initial patient contact. Why doesn’t the protocol begin with Dispatch Diagnosis?

I work in the same state. The protocols have changed since the study, but dispatch is only mentioned three times in my paramedic protocols. All of these times are only related to cardiac arrest.

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Maybe I will write a Part III. Maybe, if I do write it, it will not take over two years.

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Footnotes:

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^[1] Influence of sex on the out-of-hospital management of chest pain.
Meisel ZF, Armstrong K, Mechem CC, Shofer FS, Peacock N, Facenda K, Pollack CV.
Acad Emerg Med. 2010 Jan;17(1):80-7.
PMID: 20078440 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine

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Meisel, Z., Armstrong, K., Crawford Mechem, C., Shofer, F., Peacock, N., Facenda, K., & Pollack, C. (2010). Influence of Sex on the Out-of-hospital Management of Chest Pain Academic Emergency Medicine, 17 (1), 80-87 DOI: 10.1111/j.1553-2712.2009.00618.x

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Whenever pathetic intubation success rates are discussed, this complex, almost impossible intubation becomes one of the excuses for the low intubation success rates.

The problem with the example is that we are supposed to assume that intubation is the right thing for this patient.

Wrong.

How hypoxic are we trying to make the patient?

How long are we trying to delay extrication?

If the patient needs an airway right now, why are we messing around with an endotracheal tube, rather than using our heads?

Don’t we have more important things to do that stroke ourselves in public?

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This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight.^[1]

Also a difficult situation.

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The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation.^[1]

They didn’t even try?

This is the end of intubation. How are paramedics supposed to have self respect, if one of our own is going to stab us in the back, like this?

We aren’t supposed to be doing what is right for the patient, but doing what is right to make sure that nobody ever takes our tubes away.

How are we going to be able to BS people with the upside down, in a ditch stories?

Sure, they do happen.

Rather than look at them as examples of great intubation skill, we should look at them as demonstrations of a need for remediation.

Next time, we should think about what is best for the patient, rather than what will make a good war story – at least a good war story for people who don’t understand patient care.

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Click here to view the video on YouTube.

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An endotracheal tube is not significantly more secure than other airways, nor does it do a great job of keeping detritus out of the lungs.

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The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.^[1]

One sad part is that this was considered such a novel concept only five years ago.

A much sadder part is that this would still be novel in many places.

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Footnotes:

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^[1] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed - indexed for MEDLINE]

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Why do we work so hard at keeping resuscitation rates low?

Rates of bystander cardiopulmonary resuscitation (CPR) in the United States are dismal. A national study showed that only 31% of patients with cardiac arrest treated out-of-hospital received CPR from a bystander.¹ The low rates of bystander CPR, a procedure developed over 50 years ago, is particularly notable when compared with the great progress that has been made in making a much newer technology—percutaneous coronary angioplasty—highly accessible.^[1]

We could recognize this dismal level of bystander CPR chest compressions.

In America, we seem to be trying to demonstrate how much more intelligent people are in other countries. Here, we have only isolated pockets of high bystander CPR rates.

We spend our time making excuses for the higher resuscitation rates is these places. Seattle is #1, again – and again – and again – and again – . . . .

But they call fine V Fib (Ventricular Fibrillation) asystole! –

Is there any validity to that claim?

Probably not.

Is there any evidence that fine V Fib is in any way more responsive to defibrillation than asystole?

Is there any difference between what the critics of Seattle think of as a shockable rhythm and what is programmed into AEDs (Automated External Defibrillators)?

If these critics are so offended by Seattle’s high resuscitation rates, maybe they should submit their own resuscitation rates with their version of fine V Fib and without. Will removing their fine V Fib result in results that compare to Seattle’s resuscitation rates?

Or is the secret of Seattle not the way they measure V Fib, but the way they encourage bystander CPR chest compressions?

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Is a cath lab useful without bystander chest compressions?

Is adding more cath labs an expensive way of avoiding the real problem – low rates of bystander CPR chest compressions?

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In addition, angioplasty fits our medical model. A person has a medical problem. A subspecialty physician treats it with a high-technology intervention in a hospital setting. Interventions that can be performed by laypersons in nonhospital settings tend to receive less attention.^[1]

A medical model of cardiac arrest treatment?

The medical model would not be the BLS treatments. Treatments that we know improve outcomes.

The medical model would be the ALS treatments. Treatments that we only hope improve outcomes.

What has dominated our attention in resuscitation?

Drugs, tubes, ventilations, . . .

We still do not have any evidence that these improve survival with good brain function. Is there any other valid way to measure outcomes?

We know that low rates of bystander CPR limit resuscitation rates, but we continue to make excuses for pushing the drugs, for pushing the tubes, and for squeezing the bag.

The captain of that engine is running that cardiac arrest. His job is to make sure there are good chest compressions and to make sure that the medics, when they arrive, don’t get in the way of good chest compressions.

It is an EMT-Basic skill to run a cardiac arrest now. The paramedics just get in the way.^[2]

We can improve resuscitation or we can support paramedic egos.

As a paramedic, I think the choice is easy. We need to improve the rate and quality of bystander chest compressions.

Bystander chest compressions save lives.

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Click here to view the video on YouTube.

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Footnotes:

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^[1] Increasing bystander CPR rates: the chest compression-only method puts the goal in easier reach.
Katz MH.
Arch Intern Med. 2011 Jan 10;171(1):87-8. No abstract available.
PMID: 21220665 [PubMed]

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^[2] Medical Direction Issue
Interventions
Medical Direction Issue.

Dr. Sporer Interview.

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Some people may have seen too many movies,

or may have forgotten to take their Ativan,

or may have been promoted well beyond their level of incompetence, . . .

A gag grenade mounted on a plaque that said “Complaint department: Take a number” led to the evacuation Thursday of an office building near ground zero,^[1]

Just a little office building (the itty-bitty one in the middle) –

Image credit.

For perspective, I drew in a grenade to the same scale as the building in the picture (not the scale of the people in the foreground). That grenade is here ->

No, that was just some dirt on your screen. You cannot see the grenade at the same scale as the picture. If I were to use a period to represent the grenade, it would be much too big. Much too big -> .

If Horton called for the evacuation, that might be understandable, but this was a human in a position of responsibility.

I’ll be he, or she, was thinking You Can’t Be Too Careful!

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Same building. Different view.
 

Image credit.

Same grenade. Different view ->

We still can’t see the grenade.

But it’s next to Ground Zero!

And?

The grenade came from Oklahoma City. They get American made terrorists in Oklahoma City. Does that entitle them to similarly foolish behavior?

What if it came from Illinois?

In Illinois, they have Illinois Nazis!

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Here is a big picture of the grenade.
 

Oh, no!

I should have warned you. You might have soiled yourself.

I should have given you time to evacuate the internet, because You Can’t Be Too Careful!

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Several employees said an announcement came over the building loudspeakers telling them to evacuate as quickly as possible. Octavio Diaz was wearing a neon yellow backpack as he helped lead his co-workers out of the building to a nearby volleyball court, where they waited until the all-clear.

“Stuff like this happens, so you’ve got to take it seriously,” he said. “We’re ready to go.”^[1]

I hope they take this as seriously as I do.

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If the grenade had been real, it could have destroyed — what? — a room. Of course, there’s no downside to Brookfield Properties overreacting.^[5]

Yes, Bruce Schneier is being sarcastic.

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What if someone brings one of these coffee mugs to work?

Evacuate the building?

Or just evacuate the break room? After all, we don’t want to overdo it.
 

Image credit.

That could be Colombian coffee.

You Can’t Be Too Careful!

Or it could just be decaf.

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Footnotes:

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^[1] Toy grenade prompts NYC office building evacuation
Published: Thursday, April 12, 2012, 9:21 PM
Updated: Thursday, April 12, 2012, 9:51 PM
By The Associated Press
blog.al.com
Article

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^[2] Horton Hears a Who!
Wikipedia
Article about the book by Dr. Seuss

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^[3] Overreacting to Potential Bombs
May 8, 2012
Schneier on Security
Article

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Very easily preventable.

The crash could have been much worse, since this is in a residential neighbor hood of a city with a population of over half a million people.

Image credit.

Ian Gregor, spokesman for the Federal Aviation Administration, told The Associated Press that the agency wants to lodge a $50,625 fine against Air Methods, which is the parent company of LifeNet Arizona and the helicopter’s operator.^[1]

If this was such an easily preventable crash, why is it only $16,875 per person killed? That is assuming that the fine is applied in full.

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On July 28, 2010, at 1342 mountain standard time, an American Eurocopter AS 350 B3, N509AM, descended rapidly and collided with terrain in an urban area of Tucson, Arizona. The helicopter was operated by Air Methods Corporation, as LifeNet 12, on a repositioning flight, under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot and two medical flight crew members were fatally injured. The helicopter was substantially damaged, and consumed by a post impact fire. Visual meteorological conditions prevailed,^[2]

Flight nurse Parker Summons, 41, and paramedic Brenda French, 28, pilot Alexander Kelley, 61.

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In 2008, the Federal Aviation Administration (FAA) principal maintenance inspector (PMI) for the repair station removed the repair station’s authorization to perform work at locations other than its primary fixed location.^[2]

The duty pilot performed a 7.5-minute abbreviated post maintenance check flight the evening before the accident. A full maintenance check flight conducted in accordance with the manufacturer’s flight manual should, under normal conditions, take 30 to 45 minutes to complete. Had a full check flight been performed, it is likely that the union would have detached from the boss during the check flight. Because the helicopter would not have been operating near its maximum gross weight and the check flight would have been conducted over an open area, the pilot would have had greater opportunities for a successful autorotative landing.^[2]

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The repair station technician did not properly install the fuel inlet union during reassembly of the engine;
• the operator’s maintenance personnel did not adequately inspect the technician’s work; and
• the pilot who performed the post maintenance check flight did not follow the helicopter manufacturer’s procedures.

Also causal were

• the lack of requirements by the Federal Aviation Administration for an independent inspection of the work performed by the technician.
• the lack of requirements by the operator for an independent inspection of the work performed by the technician.
• the lack of requirements by the repair station for an independent inspection of the work performed by the technician.

A contributing factor was the inadequate oversight of the repair station by the Federal Aviation Administration, which resulted in the repair station performing recurring maintenance at the operator’s facilities without authorization.^[2]

Even the FAA is at fault.

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A loose screw = 3 dead.
 

Image credit.
 

I wrote about this several days after the crash, in part because of the absurd comments being made by people who were offended by Is that helicopter really necessary? by Kelly Grayson of A Day in the Life of an Ambulance Driver.

Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out

The NTSB has finished sorting on this crash.

Read the synopsis of the NTSB findings. Just one page, but a lot of information. Or read the much longer full narrative.^[2]

The NTSB does very thorough work, which not leave much for me to add.

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Footnotes:

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^[1] Sanctions sought in fatal air medical crash in Ariz. – Crash killed the aircraft’s three-member crew
May 09, 2012
EMS1.com
Article

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^[2] NTSB Identification: WPR10FA371
Nonscheduled 14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 28, 2010 in Tucson, AZ
Probable Cause Approval Date: 05/03/2012
Aircraft: AMERICAN EUROCOPTER LLC AS 350 B3, registration: N509AM
Injuries: 3 Fatal.
Synopsis                 Full Narrative

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