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Mayo One - Non-injury incident



Date: June 27, 2015 1355 CDT

Program: Mayo One 

Type: EC145
Tail #: N145SM

Weather: Clear. Not a factor

Team: Pilot, Flight nurse, and Paramedic. No injuries reported. No patient. 

Description: 
	During a static display at the 2015 Minnesota Air Spectacular, the
	flight nurse was at the aircraft alone while the rest of the crew was
	taking a short break. While standing near the aft cabin sliding door
	speaking to visitors, the flight nurse heard the display aircraft?s
	engine starting. The flight nurse quickly went to the cockpit and
	climbed into the pilot?s seat on the right side. She observed a male
	she estimated to be in his late teens, not a six year old as described
	by some media reports, sitting in the left side of the cockpit
	starting the aircraft. The flight nurse verbally instructed the
	individual to exit the cockpit and physically moved his hands away
	from the instrument panel to prevent more controls being manipulated
	and potentially starting the second engine.   
	Once the spectator was removed from the cockpit, the flight nurse
	followed emergency shutdown procedures and pressed the two engine fire
	buttons. The aircraft did not seem to be shutting down in a timely
	manner. The flight paramedic returned to the aircraft at that time and
	climbed into the seat that the spectator had been occupying. The
	flight paramedic recalled training received a couple of months earlier
	and attempted to roll off the engine throttle. After a brief struggle
	with pushing the throttle detent, the flight paramedic successfully
	rolled off the throttle, turned off the generators, and secured the
	battery. The rotor brake was then applied bringing the rotors to a
	stop approximately two minutes after the aircraft was started.
	Immediately following the event, both crew members continued working
	at the location speaking to air show spectators since they could not
	find any air show support personnel in the vicinity to help them and
	did not want to leave the aircraft unattended. During that time, one
	of the witnesses to the event told the medical crew that a small sun
	shade had impacted the rotor blades when they were turning. Air show
	support personnel were eventually found, and the aircraft was taken
	out of service. Program leadership and corporate public affairs was
	contacted.  The aircraft was towed to the nearby base hangar for
	inspection. No damage was found. The aircraft was returned to service
	approximately a week later.
	

Additional Info: 
	An in-depth safety review related to the event was conducted and
	multiple factors were identified as contributing.  Staff members were
	quickly inundated by the number of spectators and were not able to
	maintain a constant watch over the entrance to the cockpit. The crew
	did not consider securing the doors, or disconnecting battery power to
	the aircraft as they had been to smaller public events with no issues.
	
	Large air shows are uncommon events but yet were not considered a high
	risk environment for a potential mishap during a static display.  New
	policies are being implemented to manage access to aircraft at public
	events and when an aircraft is unattended at any unsecured location. 
	
	The medical crew had been given minimal training in aircraft shutdown
	procedures yet their training was invaluable in preventing escalation
	of this event.  
	The Mayo One program was in continued communication with the Federal
	Aviation Administration?s Principal Operations Inspector throughout
	the aftermath of the event. It should also be noted that the FAA
	closed its review of the incident, citing that ?there was no intention
	of flight.?
	

Source: Keith Trepanier Aviation Safety 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 800 332 3123 or email:
coordinator@concern-network.org.

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