Safety Compass Newsletter 7-2013

8/12/2019 Safety Compass Newsletter 7-2013

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To Err is HumanBy David CarrDirector of Safety

JULY 2013

To Err Is Human

BIRD STRIKE!

Word on Lightning

Safety

2013 Incident Stats

One Final Thought

A monumental quote by a famous author, Alexander Pope.

Truer words were never spokenor more appropriate

when the topic of the month is Med-Trans newJust Culture

nitiative.

You may have heard the term, maybe you know what it

means, and maybe you have experienced it. But I want to

discuss the concept of Just Culture as we will apply it

throughout Med-Trans.

Just Culture has its own language and complex diagrams

so it can get a little confusing so lets dispense with jargon.

n its most simplified form, this is Just Culture, Ready?

Management at all levels within any company especially

one as decentralized as ours, has limited visibility on what

s going wrong at the base level. Whether it is policies or

procedures that dont translate into the real world, training

that is inadequate, safety related concerns or personnel

problems. You know better than anyone else what is

working and not working at your base.

Company Leadership needs to know what you know so wecan improve. We are responsible for ensuring that you

have the necessary tools for a safe work environment,

The two most important tenets of Just Culture are Trust a

Accountability.

Trust: We place a great deal of trust in your ability to your job with the utmost professionalism. And we trust t

you will tell us when things go wrong. You need to pla

trust in your management team to use the information y

provide to improve the safety and efficiency in yo

workplace.

Accountability: We are all accountable to each other. one at Med-Trans can accept or ignore unsafe behav

Everyone is accountable for their actions and decisions

cant imagine anyone having a problem with that. Ev

piece of the puzzle, from the mechanic who signs off

procedure, to the flight training department that ensu

pilots are proficient to the medical crew who provide l

extending care, we are all accountable for ensuring the b

possible outcome for the patient entrusted to us.

When it comes to bad news, some employers play t

blame game or sweep the information under the rug. He

is a simple example of what a blame culture looks like. Ysee something that needs to be fixed fast, like frayed

bare wires from an electrical cord plugged into an outl

You report the information, and youre blamed for eit

mishandling the equipment or youre labeled

troublemaker for bringing it up. Conversely, in an avoidan

culture, management ignores you and the problem

whatever reason, be it cost to fix the cord, or that re-wir

might slow production. Whatever. The bottom line is, eit

you become the chronic complainer or the invisible ma

take your pick.

In a Just Culture, you are responsible for reporting what y

observe, and management is responsible for finding o

why the condition exists, how it can be resolved and how

can be prevented from happening again. Staying with t

frayed electrical cord example, the condition is investigat

and the conclusion is that that the wires were expos

because youve been grabbing the cord instead of the pl

Okay, some re-training is in order. Maybe you tripped o

the cord and it pulled the wires out. So we need to find

solution to a trip hazard. Maybe the cord just was

durable enough. No problem, we have learned from t

experience and next time, we will use a more durable cord(contin

such as a healthy workplace, well-

maintained equipment, competent

leaders and co-workers, and well

thought out policies, procedures

and training.

You have a responsibility to do

your part by reporting conditions or

events that are of concern,

policies, procedures and trainingthat can be improved, and unsafe

behavioreven if its yours.

In return for your forthrightness,

management commits to finding

out the root cause of the event or

behavior. In other words, the goal

is to use the information you

provide to proactively prevent

future unsafe conditions and

events before they result in a

tragedy.


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JULY 2013

pilots and six passengers when a hawk crashed thro

their windscreen hitting the throttles, driving the engine

idle. The helo was at 850 ft, and 135 knots. Due to

chaos, the pilots did not recover the rotor RPM in time.

So, again, what will be your response if you have a mid

with big bird? Do you and your crew have a plan?

The Department of Agriculture Wildlife Division, conducte

bird strike study encompassing all strikes to dome

aircraft from 1990-2005. In that 15 year period, 64,7

bird strikes were reported, 370 of them to helicopters.

Of those 370 helicopter strikes, 67 (18%) recei

substantial damage. Although helicopters were only 0

of all strikes, they accounted for 13% of DESTROY

aircraft and 24% of injuries. 77% of bird strikes occurre

cruise flight, most impacting the windscreen with sec

place going to the main rotor system.

So, whats a crew to do? Well, applying risk managemen

this problem, we arrive at a few control measures. First

foremost is see and avoid. Easier said than done right?

even harder to do when youre providing patient care, what about all the other times? Such as heads d

charting when you should be looking out, or becom

distracted with inside tasks instead of watching where

nose is pointed. How about flying lower than you need

At the altitudes we fly, we are operating in their world.

Hemet visors? Or glasses? They can certainly shield y

eyes in the event of a strike. But even if you have d

everything right, its always a good idea to have a plan

And CRM. Teamwork and knowing what to do when

loud bang startles you and the loud rush of air drowns

intercom communication might just be the differe

between success and failure. It certainly gave the edg

the Metro crew. In the end, that is what risk managem

really isgiving you an edge over the hazards you are lik

to encounter.

Because you were responsible and reported, and the

information was acted on properly, a hazard was

eliminated, and working together we may have prevented

a fire from starting.

The frayed wire example is a pretty minor event. But if you

have been reading your work email lately, then you knowthat recently, an employee reported an extremely serious

breach of professionalism. That report led to an

investigation and decisive action was taken. One

employee, doing the right thing, may have prevented a

catastrophic loss of life. Management utilized the Just

Culture process to come to an objective verdict on the

behavior involved. So our beta testing has already

started.

If you have a safety concern, or if something in your

operation doesnt seem right, you have tools available.

First, you can speak up. Or you can submit a hazardreport, or, you can talk to your supervisor. If you are

uncomfortable with any of those options, you can contact

our compliance hotline anonymously at: 800-399-2319.But lets be clear tnot okay to ignore what you know is wrongI have been focusing on Just Culture as a tool for a safer

workplace, but Just Culture is bigger than that. Just

Culture can be used to improve our medical processes,

our compliance with regulations, our training, our morale

and our interpersonal working relationships. Anytime

safety, our values or our conduct is in question, Just

Culture plays an important role. In the August edition of

the Safety Compass Newsletter, I will provide details on

our move from Just Culture theory to Just Culture in

practice.

BIRD STRIKE!

Did you know that on average, we experience one bird

strike every month? Fortunately, most are minor. Last

month I passed on a story of a Metro pilot who

encountered 5 ducks crashing through the windscreen,

ripping off his NVGs. Skill and CRM saved that crew.

Have you thought about what you would do if a B1RD fails

to see and avoid you?
http://upload.wikimedia.org/wikipedia/commons/1/15/IAF_UH-60_after_birds_strike_inside.jpghttp://upload.wikimedia.org/wikipedia/commons/8/86/IAF_UH-60_after_birds_strike_outside.jpghttp://www.flightglobal.com/blogs/unusual-attitude/Astar%20birdstrike.jpg


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ONE FINAL THOUGHTOn the 237thanniversary of our independence

On the 19 of April, 1775, was made the first forc

resistance to British aggression. On the opposite bank st

the American Militia. Here stood the Invading Army and

this spot the first of the Enemy fell in the War of t

Revolution which gave Independence to these Un

States.

By the rude bridge that arched the flood,Their flag to April s breeze unfurled,Here once the embattled farmers stoodAnd fired the shot heard round the world.Ralph Waldo Emerson

JULY 20

BH4071stQuarter 2013

Human Error: 2

Environmental: 4

Material Failure: 2

Directed Laser: 0

2nd Quarter 2013

Human Error: 3

Environmental: 1Material Failure: 3

Directed Laser: 1

EC-1351stQuarter 2013

Human Error : 1

Environmental: 1

Material Failure: 1

Directed Laser: 1

2nd Quarter 2013

Human Error: 1

Environmental: 3Material Failure: 1

Directed Laser: 0

Director of SafetyDavid [email protected]

The Med-Trans Leadership TeamChief Operating OfficerRob [email protected]

Director of OperationsBert [email protected]

VP, Program OperationsConnie [email protected]

Director of MaintenanceJosh [email protected]

Chief PilotDon [email protected]

Assistant Chief PilotMike [email protected]

VP, Flight OperationsBrian [email protected]

A WORD ON LIGHTNING SAFETY

For the average person, the chance of being struck by

ightning is 1 in 10,000 over an 80 year lifespan.

Working out in the open, around large metallic objects

could influence that ratio in a decidedly negative way.

The world record holder for surviving the most lightning

strikes goes to Roy Sullivan, who was struck seven times

over his 71 years. Six of those strikes occurred while at

work as a park ranger in VA. Again, Im thinking that

occupation influences exposure.

70% of deaths due to lightning strike

occur from June-August. In 2012, 39%

of deaths were due to the person seeking

shelter under a tree.

When you are at work or at play, be mindful of the risks

around you. That goes double when storms are present

and lightning is possible. Discontinue your preflight, get offthe aircraft, leave the pad, seek cover...except not under a

tree. Dont bet that you will be as lucky as Roy Sullivan.
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The Med-Trans Safety Compass monthly newslett

is one method we have of communicating with eve

employee. We want this newsletter to be a forum f

fostering a culture of informing and learning.

I welcome your suggestions on topics you would lik

to see addressed here. Better yet, send me yo

article and I will get it added in the next issue.

Feel free to contact me by phone or email, my virtu

door is always open.

David Carr

Director of Safety

Safety Compass Newsletter 7-2013

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Transcript of Safety Compass Newsletter 7-2013