Measuring Our Safety-ness

By David Carr
Director of Safety














































APRIL 2013



Measuring our
Safety-ness

A Wire Reminder
From Hero to Zero in
.25 Seconds

Reporting WX Incidents


2013 Incident Stats

Recent Incident
Summaries




When I first arrived here in February, I was curious to find
out how a company as decentralized as ours was able to
maintain control of day to day operationsoperational
control in aviation parlance. My previous two safety jobs
had been with companies who had all their employees and
equipment located in one geographical area. It was easy
to reach out and touch whatever needed attention.

What I found out during my first dizzying month here is
that control of our day to day operations is tied to the
guiding philosophy and the reason your base is a Med-
Trans base. That is, we all fit into the same general
culture. That doesnt mean were all the same, what it
means is that we all have our priorities and values aligned.

When I first started out in commercial aviation safety, my
new boss asked me, how do we measure how safe we
are? That took me by surprise. In the military, safety was
part and parcel with everything we did. We didnt have to
measure itsafety was synonymous with our culture.

A safety department was a first for this company so the
CEO was eager to leverage his new asset. He was trying to
figure out how to present our safety-ness to potential
clients as a way of separating us from our competitors. His
But that is specious reasoning. To borrow a quote from the
investment industry, Past performance is no guarantee of
future gains. As I said before, there are many companies
plying the skies who are accidents waiting to happenthey
just havent experienced one yet. Conversely, there are
operators doing things right but still experience losses.

Measuring how safe we really are is important. It is of great
benefit in making a business case. Its also important to
determine whether our efforts at improving safety are
working. After all we cant manage what we cant measure.
But lets first start with making sure everyone at Med-Trans
is an active participant in our safety culture. When
employees agree to operate by a common set of ideals,
values and beliefs, synergy is created. Synergy is a very
powerful tool in creating a safety culture second to none.
Listed below are my thoughts on a common set of ideals to
ensure we achieve and maintain a strong safety culture:

1. We lead by example. We do the right thing. We
dont take shortcuts.

2. We dont accept unsafe behavior from ourselves or
from our co-workers.

3. We dont punish employees for making honest
errors, we correct them. We cant improve if we
arent learning from our mistakes.

4. Continuous improvement is critical to our success.
We must be willing to actively seek ways to better
ourselves and our operation.

5. We dont make excuses for substandard
performance. We acknowledge our shortcomings
and fix them.

6. Safety is not our business--its how we conduct our
business.

7. If something isnt right we stop, assess and resolve
it before resuming. We NEVER accept unnecessary
risks.



idea? Measure safety by the lack
of accidents. The more I thought
about it, the less convinced I was
that this was a good unit of
measurement. There are many
companies out there cutting
corners and breaking rules and
they havent had an accident,
theyve just been lucky. Without
knowing it, I think my boss was
really asking me: give me your
business case for being here. As I
soon learned, safety, just like
every other aspect of a business
must add value. Otherwise, it is a
distraction, robbing the company
of time, effort and resources.

On the surface, a company with an
accident free record has an
advantage over its competitors
who have suffered tragic losses.




























































APRIL 2013
One last thing. If youre a medical crewmember, remember
its your butt in the aircraft too. If your pilot is doing a space
shuttle entry when landing on scene or even at a hospital
for that matter, speak up. One day (or night) youll be glad
you did.


From Hero to Zero in .25 Seconds
By Matt Harvey
On the evening of 7 March, I made one of those mistakes
that after you do it you tell yourself, what the heck was I
doing? It was approaching shift change and the helicopter
had been staged outside for most of the day in preparation
for flights. Our hangar is a co-use hangar and the local FBO
tech had come down to move a private fixed winged aircraft
out of the hangar to conduct maintenance. It was at that
time I decided to move the helicopter in for the evening.
Temperatures were beginning to drop and it would facilitate
the on-coming pilot the ability to prefight in a heated and
well-lit environment.

The Med Crew were co-located with me and the plan was
that the nurse would operate the hangar door and the
paramedic would assist me in bringing the helicopter into
the hangar once the fixed winged aircraft was moved out of
the way. You think, sounds great, whats the issue. Well,
this is about the point where I equate this to a guy who has
already moved the transporter out of the hangar and had
positioned it under the helicopter. The nurse was at the
hangar door control panel and the paramedic was helping
the FBO tech clear the fixed wing as it was pulled out as to
not have it contact our helicopter or the hangar. It was at
this point that I decided in order to save time I would, on
my own, lift the helicopter and strap it down. This way, once
the fixed wing was out of the way, the paramedic and I could
move it inside. At this point you can probably see where this
is going and I should have seen it, as well.

From the front, the transporter appeared to be squarely
positioned under the helicopter and with the transporter in
the full down position a quick look from the starboard side
showed the right hand cradles to be lined up. So, if the right
is lined up, the left must be good, right? Wrong! What I
didnt notice is the fact that the transporter was not parallel
under the helicopter, so while the right may have been lined
up, the left cradles were out of alignment to the aft. If I
would have checked both sides as well as raised the


(continued)
.



A Timely Wire Reminder



By Don Savage
If youve been flying EMS for any length of time, Im sure
you have a close encounter with wires story. In 1992,
40% of all civil helicopter accidents involved wire strikes
and while that percentage has dropped over the years,
EMS crews deal with this threat daily.

In the early days of Wings Air Rescue, one of our flight
nurses in a very calm voice told the pilot during a night
scene landing that she could see a set of wires out her
door. The pilot stopped the approach and hovering there
asked, how far. She responded, Im not sure but I
could reach out and touch them. It turned out that this
was the thin grounding wire that stretches across the tops
of high tension towers!

Again, years ago at Arizona Life Line a pilot made a perfect
approach into a night LZ. As he was shining his night sun
up to check for obstacles he noticed a wire was stretched
across the top of his turning rotor! He and the medcrew
never noticed it during the recon or landing.

So how do we avoid becoming a wire strike statistic? Pay
attention during the high reconnaissance. Most wires and
obstacles will be below 200 which means youre
minimum recon altitude should be no lower than 300 day
and 500 night. Are you too busy looking at the accident
scene? That could mean youre missing Important safety
information on your orbit or planned approach path.

Most importantly, fly your approach the way Med Trans
teachesSLOW and STEEP. Slow gives the pilot and crew
time to see and avoid wires and Steep shortens the
obstacle zone. Are you looking for wires? Not necessarily.
Remember, its easier to find poles. When you see two
poles, you know where the wires are!

During confined area training with new hires, I tell them
there are wires on the approach that are almost invisible.
Guess how they approach? Extremely slow and careful.
They sweep their light from side to side, up and down as
they creep inch by inch until they are down. When they
ask where the wires are, I say there arent any but they
didnt know that. Just like EVERY off airport landing!































































transporter up to just below the skids I would have picked
this up. My assumption was actually me accepting an
unnecessary risk. In the composite risk management
process you are supposed to identify the hazard, access
the hazard, develop controls, implement controls,
supervise and evaluate. I failed at this on multiple levels.
As I rose the transporter and it took the weight of the
helicopter the sound of crunching fiberglass let me know
that I had just made a grievous error.











How can we keep this from happening again? Simple,
follow the standard (see read & initial memo dated 18 Mar
13), assume nothing, use your team, and double check.
Remember, it only takes one oh-crap moment to undo a
myriad of previous above average performance. So, what
can the Med-trans pilot reading this article take away from
this? In the wise words of my Father you can listen to me
or you can learn the hard way. Unfortunately, in this case,
I chose the hard way, but if you can learn from my mistake
and add it to your tool chest of items to be on guard for, it
can add a positive light to an otherwise negative situation.

Reporting Weather Incidents








By David Carr
Which is better? Being on the ground wishing you were in
the air or in the air wishing you were on the ground?

Nothing is more important than making the right decisions--
especially when the decision is to discontinue a flight.
Weather is one of the greatest threats we face and we
need to treat it with the utmost of respect.

Heres a typical scenario most of us no doubt are familiar
with: Everything starts out fine. The weather isnt CAVU,
but its still okay to launch. So you strap on your flying
machine and off you go, because after all, youre here to
save lives and you cant do that from the La-Z-Boy. Then
somewhere enroute, it gets a little darker overhead, and
grayer out front. Quietly you curse NOAA but tell the
medical crew that everything is fine. Soon, you find
yourself lowering the collective a little at first, then more.





APRIL 2013

When that doesnt work, your instinct tells you to slow down.
The gray gets darker. Rain starts pelting the windscreen.
You slow down some more. Hopefully before your courage
isnt quite on E you spot a nice clearing down and to the
right. As I said, hopefully. Some continue, betting that it will
get better just up ahead. They press on, descending and
slowing, squeezing the safety margin to almost zero. Some
find themselves staring at a white windscreen unprepared
for what to do next. What a bad position to put yourself in,
straining to see through bad visibility, youre low and getting
lower, slow and getting slower when, poof, nothin but
white?

We EXPECT you to discontinue a flight when it is inadvisable
to continue. Thats why we made you PIC. You have
demonstrated the judgment and decision making ability to
know when to say when. Your first choice should be
controlled flight to suitable terrain of your choosing, but if
thats not possible, then making a command decision to
transition from visual to instrument flight. Regardless of
which option you choose, there will be no quibbling or
second guessing your decision from the peanut gallery.
That is our 100% guarantee.

But when its all over, we need to know what didnt work so
that we can make improvements to our operation. Thats
where reporting comes in. Maybe youve been getting bad
weather advice from your on-line resources. We need to
know that so we can help fix it. It may have been nothing
more than a long leg over an area of inadequate weather
reporting capability. Or maybe it is just weather dynamics
typical in your region. Well, if we have data that shows
weather aborts are common at your base, we can build that
knowledge into the training program for the crews, from new
hire training to devoting extra time on IIMC or unusual
attitude recovery.

Discontinuing a flight when you believe it is inadvisable to
safely continue is the right thing to do. After all, its better to
be on the ground wishing you were in the air than the other
way around. You know what I meanweve all been there.
On March 12, the FAA accepted Med-Trans
into their Safety Management System (SMS)
Pilot project, joining numerous Commercial
airlines and a few selected HEMS operators.
This is an important step for our company. We have
entered into cooperative relationship with our FAA
Certificate Management Team (CMT) to develop and
implement an SMS that will improve the safety of every
facet of our company. One of the first changes you will
see is a migration away from paper based reporting to a
web based incident reporting system to report all safety
related events, incidents or concerns, patient incidents
and employee injuries. Expect updates on changes
within the next few weeks.































































The incident summaries provided here have been collected from around the industry and are shared for general awareness
purposes and in the interest of flight safety.

BH407
1
st
Quarter 2013

Human Error: 2
Environmental: 4
Material Failure: 2
Directed Laser: 0

EC-135
1
st
Quarter 2013

Human Error : 1
Environmental: 1
Material Failure: 1
Directed Laser: 1
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
APRIL 2013

Maintenance
On December 7, 2011, about 1630 Pacific standard time,
a Sundance Helicopters, Inc., Eurocopter AS350-B2
helicopter, N37SH, operating as a Twilight tour
sightseeing trip, crashed in mountainous terrain about 14
miles east of Las Vegas, Nevada. The pilot and four
passengers were killed, and the helicopter was destroyed
by impact forces and post-impact fire. The helicopter was
registered to and operated by Sundance as a scheduled
air tour flight under the provisions of 14 Code of Federal
Regulations (CFR) Part 135. Visual meteorological
conditions with good visibility and dusk light prevailed at
the time of the accident, and the flight operated under
visual flight rules.

The helicopter originated from Las Vegas McCarran
International Airport, Las Vegas, Nevada, about 1621 with
an intended route of flight to the Hoover Dam area and
return to the airport. The helicopter was not equipped, and
was not required to be equipped, with any on board
recording devices.

The National Transportation Safety Board determines the
probable cause(s) of this accident to be: Sundance
Helicopters inadequate maintenance of the helicopter,
including:

1. The improper reuse of a degraded self-locking nut;

2. The improper or lack of installation of a split pin;

3. Inadequate post-maintenance inspections, which
resulted in the in-flight separation of the servo
control input rod from the fore/aft servo and
rendered the helicopter uncontrollable.

Contributing to the improper or lack of installation of the
split pin was the mechanics fatigue and the lack of clearly
delineated maintenance task steps to follow. Contributing
to the inadequate post-maintenance inspection was the
inspectors fatigue and the lack of clearly delineated
inspection steps to follow.
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

NTSB Chairwoman Deborah A.P. Hersman said, "This
investigation is a potent reminder that what happens in the
maintenance hangar is just as important for safety as what
happens in the air."