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Life-saving missions

Ejection Decision

By Daniel Foulds

Published on: October 6, 2016
Estimated reading time 15 minutes, 6 seconds.

The pressure to continue a life-saving mission can be overwhelming. When the stakes are high but the risk is higher, how do you make the decision to abort?

It was the last hour of the last night of a week’s worth of work. I had rolled out of bed, cleaned up, straightened up, and was making coffee. A week off beckoned. In my mind, I was already on the boat.

Alert tones sounded across all three radios in our quarters.


I listened to the scene-flight assignment, and told the comm-center I would check weather. I didn’t want to go, but the ceiling and visibility weren’t bad enough to get out of the flight. The forecast was okay. No mention of fog, but we had a conjoined temperature and dewpoint.

“Base, LifeStar responding.”

My nurse that morning was Jillian. She is a veteran of trauma-centers in South Africa. Real trauma centers. Don was the medic. We had worked together for a couple of years. I had helped him work on dead people, who then proceeded to be undead. We had a bond of trust. He had skills. I had skills. We liked each other.

We headed northwest from Savannah into the country. Once you cross I-95, it’s a different Georgia. Rural. Two-lane roads. Pastures and plows and pine trees. Daylight was fresh upon the world, and the air was still and heavy. The vents for the air conditioning were streaming a cool, moist fog; the system in a BK117 cools the air, but doesn’t remove moisture. The air outside was saturated, but still clear. Heavy gray clouds hung low overhead. “At least it’s daylight…”

Life-saving missions
The pressure to continue a life-saving mission can be overwhelming. When the stakes are high but the risk is higher, how do you make the decision to abort?

Thirty miles northwest and we came to our scene, a country crossroad at which a truck and car had arrived simultaneously, neither stopping. The truck won. I got the landing zone briefing over the radio, did a recon, and landed in a field. My crew tromped off to get the victim. I started working on forms.

Don came back.

“Can we take two?”

“What’s their total weight?”



“Okay, it’s going to take a few minutes — the lady is entrapped pretty badly. These people are circling the drain.”

“Roger that.” I set up the GPS, and entered frequencies into radios. I called the comm-center and advised “two patients, both trauma-alerts.” After a 20-minute delay, the procession headed to the helicopter: firefighters, medics, and my crew — one per patient. We loaded with the engines running, and after the helpers were clear I advanced throttles and asked for the before takeoff checklist.

Don called off the checks. I responded and asked him to clear us left, right, and overhead.

We blasted off.

As soon as I cleared the trees, I could see tendrils of mist coming up out of them. The atmosphere had become sufficiently saturated to produce fog, and it was happening rapidly.

I was now in a race.

I could hear Don and Jill working, talking about what to work on first. Blood was coming from multiple injuries. They were very busy. I gave a short report to the comm-center and said that the crew might be too busy to call. “Please have help at the heliport.” As we neared the coast, the visibility got worse. I began to feel the gut-ache of pressure. I heard a Delta pilot tell Savannah that he needed to hold west of the airport for some weather.


I called Savannah approach, used “Lifeguard,” and asked for direct routing to the hospital. The weather got worse. The patients got worse too. I could hear fatalism in the crew’s voices.

Then the voices in my head started. “Go faster. Faster. You have to get them to the hospital — now!” This was countered with, “The weather is going south. You need to stop somewhere — now.”

We rolled across I-95, and I changed to the tower frequency. The tower controller announced two miles of visibility and said, “What are your intentions, LifeStar?”

“I need a special VFR clearance across the airport at 500 feet, I have two crash victims on board. I am trying to get them to Memorial.”

I was totally caught up in the drama. Patients dying. Not enough weather. Not enough time. No good choices. What to do, what to do, what to do?

I was in a “naturalistic environment.” These require “naturalistic decision making.” Making choices when a lack of time to think is coupled with extremely high consequence is hard. It’s excruciating.

My crew and I and those two dying patients? We were between a rock and a hard place. I could sense that I wasn’t making good decisions.

Human factors were working against me.

We blew across the runways at Savannah International. A safe landing was right there for the taking. My head said, “Land! Call for an ambulance. Stop!”

My heart said, “They will die.” I was very uncomfortable. I called the comm-center to update them. Jill could hear the anxiety in my voice. She said, with her accent, “Daaan, you are doing a wonderful job…”

I didn’t feel wonderful. Another pilot flying a helicopter 10 miles ahead came on the frequency and advised that the weather was much better where he was.

The runways disappeared behind us.

I was down to 300 feet. Only five miles to go. I was thinking aloud, “Okay, where are the towers between the airport and the hospital. Don’t hit a tower. Don’t hit a tower.” I was leaning forward, almost to the glare-shield. The visibility was getting worse and worse. I could see the ground below me, but not much to the front. I had taken us into the clouds in a visual flight rules (VFR) helicopter without an instrument flight rules (IFR) clearance.

“Man. What a mess.”

I wasn’t worried about flying in the clouds, because I did that frequently both in military service, and while flying for Penn State and Geisinger’s IFR flight programs. I was, however, acutely worried about hitting something. I knew I could climb and get a clearance and shoot an approach. A part of me wanted to. But that would take time. And blood.

The pressure was like a piano on my back.

But it was all in my head. The entire situation was something that my cognitive and emotional selves had concocted, but that my behavioral self was having a hard time resolving. I was taking my crew and those two patients further and further into an untenable situation. Why?

Good helicopter emergency medical services (HEMS) pilots don’t earn their pay for always saying yes. Good HEMS pilots earn their pay for having the wisdom and courage to say no. And we can say no (further) at any stage of a flight. We don’t have to press on. The fact that the patient might die is not a valid justification for us all to die. Or to accept undue risk. It’s okay to stop. It’s a harsh truth, but truth it is… even if there is a kid involved.

I know this now. I learned that lesson that day. I lived because of dumb luck. I didn’t hit a tower by sheer chance. I flew by a crowd of them. I stumbled across a military airfield near the hospital and finally came to my senses.

“Tower, LifeStar declaring an emergency, landing at Hunter Base Ops.”

“Comm-center, send two ambulances to Hunter Base Ops please. I am landing for weather.”

I shut down, climbed out, and felt horrible. What a mess. I opened the clamshells and the back of the aircraft looked like a combat hospital. Blood dripped off the floor onto the cement. Jill and Don were both sweating, working, trying.

The ambulances arrived with reinforcements. Grim faces.

Both of those patients died. They would have died no matter what I did, and I could have killed us all trying to save them. This is a hard lesson. It’s okay and understandable to feel compassion for our patients. But our prime directive is to save the crew. Every decision we make should be with an eye to that end — that our crew goes home safe at the end of their shift. Save the crew. Let the crew save the patient. They can work toward this either in the air or on the ground. You don’t have to keep going.

In an excellent old U.S. Air Force training film Ejection Decision – A Second Too Late (available on YouTube), the Air Force explored the phenomenon of fighter pilots waiting too long to eject from a crippled jet. This happens less often in combat environments, perhaps due to less worry about destroying an aircraft. They show graphic images of planes crashing, sometimes accompanied by a blossoming parachute, sometimes not. The message is clear. When the jet fails, you should eject. Don’t wait. Don’t try to sort things out. Remove yourself from that situation. There isn’t time for reflection. There is too much pressure.

There is too heavy a price for hesitation.

More than one pilot being interviewed stated that his decision to eject wasn’t made in the heat of the moment. The decision was made years before, in training, after careful thought. “If I encounter these conditions, I will take this action.” These guys made their decision early. When they encountered the conditions they acted. Without thought. Without hesitation.

If you are a HEMS pilot, you should make your “decision to eject” now. Before you are sitting in the hot seat with someone dying next to you. Weather, maintenance, fuel state? It is going to happen to you. And if you hesitate, you may not be as lucky as I was that morning, all those years ago.

HEMS flight teams: When a patient is on board, are the crew absolved of any obligation to monitor the man-machine-environment? What could/should the crew have done when they heard the obvious anxiety in my voice and saw the low altitude I was flying at to avoid the clouds? It is easy for a team to become so focused on the objective that they accommodate to excessive risk, as one. When this is happening, someone must think and speak rationally — it may have to be you.

Join the Conversation


  1. At a seismic camp in the Sudan I was flying a Bell 212 and the camp manager at around 2:00 am asked if I would fly into a local airstrip with a patient who was having heart problems to have him transferred to Khartoum. I stated that I would look at the weather, talk to my crew and analyse the situation. The Sudan in the summer season is very dark at night, the only way I could fly would be within fifty feet above the ground (landing lights on) as the aircraft was not equipped IFR and I was not current. The patient once at the airstrip (dirt ) if I managed to get him there would not receive any better treatment than was available at the camp. I stated that I would take him to the strip at first light the same time the aircraft would arrive to take him to Khartoum. Flight was cancelled, the patient died at 4:am and I transferred his body to the airstrip at 8:00.
    am. My concern was for the crew and aircraft and my ability.

    1. Well, well done, Don. The one thing definitely worse than losing a patient, is losing a crew, isn’t it. Let me never hear criticism of a pilot saving a crew. There’s enough criticism of those that don’t.

  2. As a Coast Guard Aviator, I can closely relate to this experience myself. “The entire situation was something that my cognitive and emotional selves had concocted, but that my behavioral self was having a hard time resolving,” really pinpointed that unwelcome feeling. It is not a good place to be. Your words will help others play out similar situations in their minds and hopefully develop personal stop gaps, limits, wisdom, and the courage to say no. Thanks for sharing your story. I forwarded it to my unit’s aviation cadre.

    1. Excellent. We all end up there sooner or later, until we learn not to. Not sure who said it “Good judgement comes with experience, experience comes from bad judgement.”

      Here’s to hoping we can teach some good judgement Dan!!

  3. As a Coast Guard helicopter pilot, your story stuck a chord, especially this:

    “My head said ‘Land! Call for an ambulance. Stop!’ My heart said, ‘They will die.'”

    I recently had a SAR case in some terrible Alaska weather where my fellow pilot used “decision gates” – predetermined limits that initiated some kind of action (if we encounter less than 1/4 mi vis before this point, we turn around… if we encounter heavy turbulence at the mouth of this valley, we abort… etc). It is nearly impossible to make value-based decisions in the heat of battle… Your advice to make some decisions early, before the “cognitive” and “emotional” selves have begun to disagree, is solid.

    Thanks – I’m taking this story back to my fellow pilots.

  4. Excellent piece, I can’t thank you enough for relating this experience. As level headed as pilots are trained to be, CFIT seems to be a repeated killer.

    I count myself as cautious, rational, insightful and skilled, and I’ve still found myself in this situation! WTH!?

    Doing military flying in DRC a few years back, my embarrassing story goes like this: the airfield is next to an enormous lake in a bowl of mountainous terrain, with two +-13k’ volcanoes to the north. It has VOR, NDB & ATC but they’re as reliable as a soggy napkin, as was my recently qualified copilot. We were given mid-1900’s Russian maps with little detail and unintelligible markings. There’s no weather service and the weather is almost totally unpredictable. The nature of terrain, LZ distances and routes used don’t guarantee any reliable corridors in bad wx. Carrying a delegation back from an unsecured LZ in the middle of nowhere, we encountered a lowering cloud base as we got about 1/3 way back home. Eventually the cloud was lower than the tops of all the mountains and hills on our route. I aimed for lower ground and was forced to take random valleys in the general direction of home to keep the speed up and the helicopter airborne. Landing was impossible due to the surrounding hundreds of square miles of deep forest canopy and potentially hostile forces. Using the HDG bug and CRS needle to keep track of the last two valleys’ tracks in case we had to turn around at a dead end. And then we met one. A behemoth of a rock blocking any possible progress. Considering the surrounding terrain I elected to reduce speed to Vx in a wingover style tight turn and got heading back up the valley, which by now of course was looking worse than when we flew down it the first time!

    Knowing that the door was closing (arguably it was already closed), I elected to climb for the tiniest gap in the clouds (at least that’s what it looked like) and route back avoiding the thunderstorms with radar, hoping to avoid the volcanic mountains which they were pushing us towards. Closer to home the weather improved enough to resume ‘normal’ routing.

    Writing this now I can’t believe I got myself into that situation. I’m horrified. Looking back, I still can’t figure out how any missions would happen under those circumstances without taking significant risk. Like in your piece above, it’s best to have clear decisions made in advance, but emotion and ‘necessity’ complicate things infinitely.

    Keep the crew alive, a good motto.

  5. On SAR missions in poor weather I always kept in the back of my mind “One funeral is better than five”. Hard though it is to turn back, there’s no point turning you and your crew into martyrs. One of the closest shaves I had, while still a co-pilot, was on a mission across Scotland in the small hours of Boxing Day 2003 – complete with gale force winds and blizzards, and terrible light levels due to the clouds being stacked up – to get some overdosed drug addict who was (so we were told) guaranteed to die if we didn’t deliver him from a tiny medical facility on an island off the west coast to the big hospital in Aberdeen. As we made our way along a tight valley at low level, the snow got thicker and thicker, and we turned away several times but then continued when the visibility improved slightly. As the snow clamped again, the captain turned sharply away, only to find a mound sticking up from the valley floor. By the time we saw it there was no time to avoid it and through sheer luck we cleared it, but not by much. We then had a sixty-mile trip back to base with a strong tailwind, which presented its own challenges, plus the worry of having abandoned the casualty, and several aircraft systems failing en route (first the radar, then one of the landing lights failed on – not a good thing when using NVGs in snow!). However, we made it – and so did he! When we gave up, the doctors decided to send him by road – a journey of nearly 7 hours in those conditions – but he survived. What a shame if had we wiped ourselves out that night for no reason.

  6. Thank you for this. I am reading it by chance because it popped up on Reddit, today, just as I’m sitting at home in my house 5 miles from KUNV, where the author used to fly. I’m sitting here because I cancelled a charity trip out to Long Island, flying a cancer patient. Not an urgent, grave situation, but I would have really liked to make the trip a bit easier for him. The reality, though: turbulence and wind shear with a cold front coming through, the freezing level, and generally low IFR conspired to make this single-pilot IFR trip inadvisable for me as someone with just a little Cessna and limited experience. One my own or with another pilot? Maybe, but not with a passenger in my care.

  7. Easy summary that I learned early on: “It’s better to be on the ground wishing I were flying, than flying wishing I were on the ground”. This thought has never failed me.

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