Childrens Hospital of Philadelphia (CHOP) - Non-injury incident

Date: 2/14/08 1952 EST

Program: Childrens Hospital of Philadelphia (CHOP)
	34th ST. and Civic Center Blvd.
	Philadelphia, Pa. 19104
	

Type: BK 117
Tail #: N116MB
Operator/Vendor: EraMed / University Medevac

Weather: Clear. Not a factor

Team: Pilot, Flight Nurse, Flight Paramedic, Specialty Crew Member. No injuries reported. Patient on board. 

Description: 
	At approximately 1952 hours, a helicopter transporting a CHOP team and
	patient was landing on the helipad on the roof of the hospital. 
	During the final approach, the pilot requested that the lights for the
	helipad be turned on.  While attempting to accomplish this, the safety
	officer inadvertently activated the foam/fire suppression system. 
	This resulted in discharge of foam and water onto the helipad, with
	the aircraft inches from landing.  
	
	Upon touchdown, the pilot kept the engines at flight idle to help
	disperse the foam and water, and none entered the helicopter.  The
	patient and crew were aware of what was happening and remained in the
	aircraft until the fire suppression system was turned off.  Other than
	a delay in off-loading, there was no harm to the patient as a result
	of this incident. The patient was transported to the receiving unit.
	
	The fire alarm activated with this discharge and the Philadelphia
	Fire Department was notified.  Units did respond and were advised that
	this was an accidental discharge. 
	
	A senior pilot and mechanic reported to the hospital.  The aircraft
	was inspected for damage from the foam and water, and none was
	apparent.
	
	Following a release from the mechanic, the aircraft was powered up,
	systems were checked, and the helicopter was flown back to its base.
	Following a more thorough inspection it was determined that there was
	no other damage to the aircraft.

Additional Info: 
	All CHOP staff, Medevac crews, and the involved security guards were
	debriefed by the leadership of CHOP Transport.
	
	The switches for lights and foam activation on the helipad are on
	separate walls and clearly marked. The foam activation switch is also
	behind a plastic cover with a "screamer" device to alert staff that
	this is NOT the light switch.  Security Leadership will be reviewing
	proper procedures on each shift with all safety officers.  A
	comprehensive review of this system is now underway.  
	

Source: Peter Brust, RN, MSN; Nurse manager

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
The CONCERN network shares verified information to alert medical transport
programs when an accident / incident has occurred. Please share the above
information with your program staff. If you have further questions, please
contact the CONCERN Coordinator, David Kearns at 800 525 3712 or email:
coordinator@concern-network.org.

Copyright 2007 ASTNA