HAVE iPhone - WILL TRAVEL
By David Carr
Director of Safety
DECEMBER 2013
HAVE iPhoneWILL
TRAVEL
Steep & Slow; Wires
Below
Applying Aviation Safety
Concepts To Reduce
Patient Error
Safety Donts
2013 Incident Stats
Beware, Tunnel Vision Ahead
I was in a rush to get to the airport for another Med-Trans
adventure. I loaded up my stuff in the back, and being in a
frenzied state of mind, opted out of opening the car door for
my wife (Error #1 of many).
I slid behind the wheel, fired up the family truckster and
backed out of the garage. Full steam ahead. Destination:
the always-glamorous DFW airport. About 10 miles into our
journey, going from 0-70-back to crawl, walk and run speeds,
we had cleared most of the traffic and realizing that I had a
free moment to multi-task, reached for my cell phone to
check which terminal I would be flying out of.
My hand searched at first then grappled and grasped,
reaching for the cellphone that is ALWAYS where I put it, in
the center console cup holdernothing but air.
1*
Pilots, being right brained are prone to setting up systems.
Procedures we mentally and physically put in place to
ensure we dont miss anything. When you have 3 radios
going off, an LZ improperly setup, and two medical
professionals prepping for the worst case scenario patient
pickup , the mission can get distracting and complicated in a
really big hurry. Cue our fallback
systems. We reach for the
checklist to run through the do-or-
hurt yourself items; you instinctively
know where all the buttons areyou
have memorized your cockpit so
youd be ready for such things; you
mentally go through a task list to
make sure all the bases are
covered, then you follow well
practiced procedures of reconning
the LZ, cause you know that when it
comes to a safe outcome, first
responders are involved, but you are
committed. These are pieces of your
survival strategy. After all, you only
have:
My search was in vain. I looked down and my greatest
fear was realized. No phone, where a phone was
supposed to be! I dont I dont know about you, but just
but just about everything of value (with the exception of my
family) is in some fashion in that phone. Precious photos,
contact list of hundreds and important notes, not to mention
it was set up exactly how I wanted it (who wants to go
through setting up a phone more than once a decade?).
My mind shifted to troubleshooting. Did my wife have it in
her purse. No. Is it in my back pocket, No. Is it still plugged
in at home. Maybe, or did I put it on the back bumper as I
was loading my stuff?
Is That Steve Jobs Spinning In His Grave?
Stage II panic. As I looked for an opening in traffic to get
off the highway, Stage II panic escalated to stage III when I
dared to consider the possibly that I had made the
unpardonable sin. I found a spot with a wide shoulder, I
eased off the gas and brought the 6000 lb. SUV to a
standstill. Even in my panicked state of mind, I glanced
out the side view mirror for traffic before opening the
dooranother piece of my survival strategy. As I
proceeded to the back bumper, my minds eye was
conjuring images of little bits of Steve Jobs wonderphone
scattered about Hwy 121. As I made the turn, I looked
down and there it was, my prized iPhone 4 resting
comfortably on the back bumper, just where I left it.
Misery Loves Company
Shown below is empirical evidence that when it comes to
leaving stuff on my vehicle, Im in good company:
The same can be said in our flight operations. Med-Trans is
averaging one incident a month of something left on, out that
should be in, connected to that shouldnt be, or hanging out
of our aircraft.
An unsecure door opens in flight. Probably not the end of the
world, unless a bed sheet goes with it. You can ask our Air
Evac brethren about that one. How about stuff left on the
ramp that a patient might need in flight. The oops gets more
serious. What about stuff left on that falls off in flight? I
wouldnt want to be under our aircraft as a radio plummets
like a homesick brick from 500 feet above (1lb @ terminal
velocity = new Med-Trans patient + lawsuit).
Why does it continue to happen? We are all trained, we are
all professional, we all care. Here are my thoughts: Much
like my adventure to the airport, we get busy, in a rush, were
kicking up dust to get stuff loaded and on our way--hey, we
have lives to save people! Somewhere along the way
though, we miss the part about backing each other up. One
last check to make sure weand our stuff are together,
secure and ready to gallop off.
POLICY BETA TESTING UPDATE
If you recall from last months Safety Compass newsletter, we explained a new approach to developing and fielding new
policies or major changes to current policies. First, the proposed policy was published for a two week comment period, then
the changes were reviewed. Ten of 13 recommendations were made and the revised draft policy was beta tested by two
B407 and two EC135 bases for two weeks.
The next step in the policy evolution is to review the feedback from those bases, make final changes and publish the policy.
The feedback comments are posted on the Sharepoint Safety Page as is the proposed policy. It will be updated periodically
until it becomes a real live policy. https://sharepoint.med-trans.net/Safety/default.aspx
Thanks to all who took the time to provide comments, recommendations and feedback. Your opinions are appreciated.
DECEMBER 2013
STEEP & SLOW; WIRES BELOW
Bill Cady
BAM, GHS Med Trans (Greenville, SC)
I informed the crew that I was going to turn on the belly lights
during this approach. (Most crewmembers ask that we not turn
these on as they reflect off of the landing gear, hindering
visibility under NVG). The crew agreed with my decision to use
the supplemental lights and we began another slow, steep
approach toward the intersection from east to west, remaining
over the highway. At approximately 30 AGL, and clear of the
fire pumper, I heard the nurse say STOP, WIRES!
I immediately arrested our descent and looked below the
aircraft. There were two wires
approximately 10-15 below us,
running diagonally from 1
Oclock to 7 Oclock. I climbed
up 20 feet and moved forward,
away from the wires and asked
the LZ Commander if he saw
he saw the wires below us. He
responded Negative, Negative,
the only wires are in front of
you. We found out quickly that
this was not true. We landed
safely on the highway and shut
down, awaiting extrication of our
patient. With the patient
successfully delivered to the
trauma center, we began
debriefing this incident. It was
agreed that two things ultimately prevented us from striking
those wires:
The use of the belly lights which allowed the nurse to see
the wires unaided, and;
Our painfully slow descent and closure rates which
allowed us to stop immediately, with minimal power input.
The nurse stated, during the debrief, that if we had not been at
a crawl, he would not have seen the wires in time to stop us,
as he could only see about 20 feet, even with the aid of the
belly lights. It was also noted that the fire department tasked
with setting up the landing zone, was the same department
whose volunteer members were just involved in the tanker
truck rollover. Were their minds in the game?
The information provided to us in our landing zone briefings is
usually good, but should always be taken at face value. Many
hazards cannot be seen from the ground or are simply missed.
High and low recons should always be accomplished and
never taken lightly. Orbit the LZ as many times as necessary
to get a complete picture of the area you are about to descend
into. Be prepared, on EVERY approach, to stop on that
proverbial dime, and fly your EMS helicopter with this
philosophy; If your picture is not on my pilots license, youre
trying to kill me. This incident is but another example of how
flying with this mindset has saved me several times.
On a recent night, with little sleep and less than an hour
remaining in our busy night shift, GHS Med Trans responded
to an MVA involving a fire department tanker which had rolled
over, trapping at least one occupant. While enroute, we were
provided with coordinates and told that the local volunteer fire
department would be setting up a landing zone for us. We
made radio contact with the LZ Commander and learned that
the LZ was being set up in a highway intersection not far from
the scene. We arrived overhead and observed two pieces of
fire apparatus arriving at the intersection.
We orbited the area numerous
times while waiting for the LZ to
be secured. The LZ Commander
advised us that a police car was
parked underneath the only wires
in the LZ and that he wanted us
to land between those wires and
his rescue truck. I noted the
position of the police car, which
was parked on the Northwest
corner of the intersection and
asked if the wires were parallel
the highway. No, they are
perpendicular was his response.
I then told LZ Command that we
were unable to tell which of his
two trucks was the rescue truck
and asked him to identify it by cardinal direction. It was to the
west of the intersection.
We identified the wires crossing the highway, finished our
high recon and began a slow steep approach/low recon
toward the rescue truck. At 300 AGL we decided that the
landing area was not acceptable and I initiated a climb out
and go around. We told the LZ Commander of our decision
to reject the LZ and he radioed his personnel to move the
pumper farther down the road. The pumper was being used
to block the highway on the east side of the intersection. We
were then told that we could land behind the pumper. This
changed the touchdown area of the LZ to just east of the
intersection, well away from the previously reported wires.
We performed a few more orbits to complete a high recon of
the new LZ. We identified a power pole in a field, north of the
highway on which we would be landing. The pole was not an
impediment to our approach but we could not determine the
direction of any wires on the pole. We saw what appeared to
be a second pole near a residential structure directly east of
the first pole. We believed that any wires on the first pole
were possibly running to that house and if so, would not be in
our path during our approach and landing. I asked the LZ
Commander to watch our approach closely and to say stop,
if he saw any obstacles in our path. He acknowledged that
he would, stating the only wires are under the police car.
DECEMBER 2013
APPLYING AVIATION SAFETY CONCEPTS TO REDUCE
PATIENT SAFETY ERRORS Part I
DECEMBER 2013
By Connie Eastlee
VP, Program Operations
In the 2000 Institute of Medicines (IOM) report To Err is
Human, it was estimated that health care errors in the
United States contribute annually to between 48,000 and
96,000 in-patient deaths.
Why Hospitals Should Fly is an excellent
book that compares the similarities between
aviation and healthcare. The author made
the following analogy. Medical mistakes
likely occur to 22-30 patients every hour of
every day amounting to a staggering total
of 100,000-250,000 unnecessary patient
injuries every year-- the equivalent of crashing ten fully
loaded Boeing 747s every week.
Air Medical Transport is a high-risk environment for health
care error due to the presence of critical and complicated
patient physiology, the high volume of tasks, extensive
multitasking and predictable gaps in the continuity of care in
transporting the patient from one place to another. (scene to
hospital etc.).
When you compare aviation safety and patient safety
literature the terminology may be slightly different but the
concepts are the same. Error exists when a planned
sequence of activities, either mental or physical, does not
achieve the intended outcome. Either the plan did not
proceed as intended or the plan itself was inadequate. An
error is a mistake, inadvertent occurrence or unintended
event in an aviation or health care delivery [that] may or may
not result in injury.
From an article in a 2012 edition of Critical Care Nurse titled
Strategies for Improving Patient Safety: Linking Task Type
to Error Type. Three types of errors are described in detail.
1. Skill-Based Errors which include Slips and Lapses. Slips
and lapses occur during automatic or skill-based tasks:
A slip is an observable, external failure in the physical
execution of ones plan. Slips generally result from deficits
in attention or perception. The failure to focus ones
attention at a critical moment during an automatic (routine)
task creates an opportunity for error. Slips and lapses may
also occur from over attention during a routine task. When
attention is placed on the wrong thing, the result is skipping
or repeating steps in the task/checklist, or even in a reversal
of the task/checklist.
Sound familiar? How many times have you given a
medication or performed a walk-around, your attention
is diverted and the dosage is different than you
intended, or a clipboard was left on the helicopter skid?
2. Lapses are internal, less visible to an outside observer.
Lapses occur from failure of memory storage and manifest
in many different ways. Lapses commonly contribute to
errors of omission, which can have serious consequences.
An example of a lapse called reduced intentionality would
be when you start walking towards the room where the
refrigerated medications or Blood product is to pick up
before a flight and enroute something distracts you and you
cant remember what you were headed in that direction for
and continue on to get in the aircraft without the medications
or blood (and you thought this was just a result of old age).
3. Mistakes occur when the actions proceed as planned, but
the plan itself is inadequate to achieve its intended aim.
Essentially, the strategy used to solve the problem is flawed.
There are two distinct types of mistakes: rule based and
knowledge based.
Rule-Based Mistakes: Selecting the wrong path involves
the acknowledgment of a problem to be addressed and
a departure from skill-based, reflective performance.
Knowledge-Based Mistakes occur when we are
confronted with novel events where skill-based and rule-
based behavior are deemed inapplicable. These
situations require deliberate and conscious problem
solving. How often do we arrive at a Critical Access
Hospital which rarely sees a pediatric sepsis patient?
The hospital staff must rely on knowledge based
behavior as skills and rule based behavior will not help.
Ultimately, most tasks are governed by skill-based or rule-
based behavior, and thus most errors occur during these
processes. Hence the use of initial and recurrent
training for skills and checklists, policies and
procedures for rules (sounds like Aviation).
But if a task is not skill-based or rule-based and falls to
knowledge-based behavior, the rate of error relative to
opportunity increases significantly.
So how do we decrease our Human Errors? Safety
(whether patient or aviation) requires error and risk
management which refers to both error reduction (limit
the occurrence of the error/frequency of the risk) and
error containment (measures designed to enhance
detection and recovery of an error/probability of the
severity of the risk).
At Med-Trans we utilize the Risk Management Matrix for
identifying Hazards (prior to the error). We have been using
a risk assessment and its associated risk management
matrix for many years. In the near future though, expect to
(continued next page)
DECEMBER 2013
Sitting in the doctors office waiting room provided me with some time to kill. I looked around and saw everyone else glued
to their smartphone. So I took the road less traveled. I was sifting through ancient editions of various magazines when I
happened upon a dogeared issue of Glamour. Instantly, I recollected my favorite part, the section in the back titled
Fashion Dos and Donts. While perusing the various pictures I stumbled on a fun idea. Why not add a lighthearted
section entitled Safety Donts at the end of each newsletter. And so, an idea was born. If you would like to contribute,
send me your Darwin-Award worthy pics and I will include them in future editions.
Here are my top shots for December. Bask in the glory of our fellow human beings putting their critical decision making
skills on display.
see risk assessments for our aircraft maintenance and
clinical operations. Both are a necessary additions to our
Safety Management System because the risks we face
include risks faced in all of our day to day operations, not
just flying. Part Two - next month on how to Reduce
and Contain Errors.
LEARN FROM THE EXPERIENCE OF OTHERSIT HURTS LESS
If you have a safety concern, or if something in your operation doesnt seem right, you have tools available. First,
speak up! Get your supervisor involved. Submit a hazard report/Safety Concern. If you are uncomfortable with
either of those options, you can submit your concerning via our compliance hotline anonymously at:
800-399-2319.
The Med-Trans Safety Compass monthly newsletter
is one method we have of communicating with every
employee. We want this newsletter to be a forum for
fostering a culture of informing and learning.
I welcome your suggestions on topics you would like
to see addressed here. Better yet, send me your
article and I will get it added in the next issue.
Feel free to contact me by phone or email, my virtual
door is always open.
David Carr
Director of Safety
Director of Safety
David Carr
David.carr@med-trans.net
The Med-Trans Leadership Team
Chief Operating Officer
Rob Hamilton
Hamiltonrobert@med-trans.net
Director of Operations
Bert Levesque
levesquebert@med-trans.net
VP, Program Operations
Connie Eastlee
Eastleeconnie@med-trans.net
Director of Maintenance
Josh Brannon
Brannonjoshua@med-trans.net
Chief Pilot
Don Savage
Savagedonald@med-trans.net
Assistant Chief Pilot
Mike LaMee
Lameemichael@med-trans.net
VP, Flight Operations
Brian Foster
Fosterbrian@med-trans.net
DECEMBER 2013
