Ideas Needed -Safety Seminar

[I_Money]

In a medical helicopter group I belong to we were talking about enhancing team work. Currently every program has a 3 to go, 1 to say no policy however in our think tank today we questioned if medical crews understand enough of the aviation side to be able to be useful team member. We are exploring the possibility of creating a seminar that covers topics that that will allow non pilots to follow the pilot decision making. So far we have:

- Weather/Weather Reporting
- Inflight Hazards
- Emergency Procedures
- Basic ATC/Airspace/Navigation
- Avionics/GPS
- Preflight/weight and balance

Do you have any other ideas?

 

[MikeD]

How about mission type and criticality, as it relates to most of the above? Such as interfacility transfer vs actual EMS, and by extension, how either will drive the pressure to accomplish the mission?

You have Inflight Hazards, you should probably have Ground Hazards too....LZ types (road/car park/grass lot), who is managing/staging/marking it, obstructions, day/night ops, landing on scene or meeting a ground ambulance elsewhere and what would drive that decision, and other factors that would determine whether or not it's good to launch on the particular assigned mission or not, or to modify it to make it safer.

 

[I_Money]

I personally dislike the notion of pressure driving the mission - IMHO the flight portion of the flight should not be dictated by the acuity of the patient. If it is a child who they are coding or a stable patient being flown for his transplant the demands on the pilot should not change.

I like the Ground/LZ Hazards - good addition

 

[Blackhawk]

I personally dislike the notion of pressure driving the mission - IMHO the flight portion of the flight should not be dictated by the acuity of the patient. If it is a child who they are coding or a stable patient being flown for his transplant the demands on the pilot should not change.

I like the Ground/LZ Hazards - good addition

That's a tough one. I know that is the party line now, but... There is already the assumption with MEDIVAC that you will probably be undertaking more risk than a normal flight in order to save someone. In normal point to point helicopter flight does it make sense to put a helicopter down next to an interstate at night? Not really as this puts added risk into the flight. Is the risk acceptable for a MEDIVAC? Probably. But then we have situations like the crash a few years ago in New Mexico where we kill someone trying to rescue them.
I like the way the military (or at least the Army), did it. At a certain risk level the decision to launch was bumped up the chain of command. They might find ways to mitigate the risk, accept the risk based upon mission importance, or cancel the mission. But they would have to sign the mission brief. No signature, no mission.

 

[Dugie8]

I'm going to get some flak for this. I don't think the medical staff should have much of a say in the go/no-go decision process and should have even less clout in questioning those decisions after the fact. It runs in the same vein as a pilot questioning method of care, we would never do it nor should we. We (pilots) don't have the knowledge or experience to make any sort of quality judgement call, same goes for the medical staff vs aviation stuff(s). Does your operation let medical staff sit up front and help with checklists and whatnot? While I think it is a good to get folks involved and let them "see" the flying, I think it is bad practice to start blurring the lines of responsibility and authority. Just like a pilot doesn't sit in the back and push meds or run the vent, medical staff shouldn't be overly involved in the operation of the aircraft.

Now, how do you do this without creating a rift between pilots and medical staff? I really don't know. There are some really big egos out there, on both sides of the cockpit door and this kind of thing is just prime for heads to butt

The real leadership needs to come from the program directors and it truly needs to be a safety first attitude that the pilots believe in. If that is truly in place with no ifs ands or buts, you won't have the level of HEMS accidents we are seeing.

 

[MikeD]

I personally dislike the notion of pressure driving the mission - IMHO the flight portion of the flight should not be dictated by the acuity of the patient. If it is a child who they are coding or a stable patient being flown for his transplant the demands on the pilot should not change.

True, but it has to be addressed. As it's one of those "400 pound elephants in the room" that some EMS folks never want to talk about.

 

[Dugie8]

Blackhawk posted whilst I was writing, but brings up a point of heartburn for me. People not going on the flight make a go decision, very poor in my opinion. Management types making a no go decision, cool, telling the crew to go when there is elevated risk, bad.

 

[MikeD]

I'm going to get some flak for this. I don't think the medical staff should have much of a say in the go/no-go decision process and should have even less clout in questioning those decisions after the fact. It runs in the same vein as a pilot questioning method of care, we would never do it nor should we. .

Here's where it gets sticky though: Your life as a pilot isn't in their hands as with them being a medical person; as they're not treating you in any way. Their lives are however in your hands. While they shouldn't be dictating how the pilot flies the aircraft, they're going to have some say in whether the mission launches or not. If the mission is agreed to launch, then the pilot should do his job regarding it...unless there are substantial changes that may dictate another continue or no-go decision.

But saying the med crew has no vested interest and therefore no say whatsoever, isn't going to be the best use of CRM.

 

[MikeD]

That's a tough one. I know that is the party line now, but... There is already the assumption with MEDIVAC that you will probably be undertaking more risk than a normal flight in order to save someone. In normal point to point helicopter flight does it make sense to put a helicopter down next to an interstate at night? Not really as this puts added risk into the flight. Is the risk acceptable for a MEDIVAC? Probably. But then we have situations like the crash a few years ago in New Mexico where we kill someone trying to rescue them.
I like the way the military (or at least the Army), did it. At a certain risk level the decision to launch was bumped up the chain of command. They might find ways to mitigate the risk, accept the risk based upon mission importance, or cancel the mission. But they would have to sign the mission brief. No signature, no mission.

At what level were MAST mission approvals made?

 

[Dugie8]

Here's where it gets sticky though: Your life as a pilot isn't in their hands as a medical person; as they're not treating you in any way. Their lives are however in your hands. While they shouldn't be dictating how the pilot flies the aircraft, they're going to have some say in whether the mission launches or not. If the mission is agreed to launch, then the pilot should do his job regarding it...unless there are substantial changes that may dictate another continue or no-go decision.

But saying the med crew has no vested interest and therefore no say whatsoever, isn't going to be the best use of CRM.

I'm not saying the med crew has no vested interest. If the med crew and medical mgmt don't trust or give the pilots the tools to make competent go/no-go decisions, this isn't a CRM problem. I am, of course, playing from the side that the pilots are competent professionals and that the med crew, while having good intentions, simple do not possess the knowledge or experience to make a quality go/no-go decision, and I am talking from a fixed wing side. Being a nervous flyer around T-Storms is not a reason to cancel or delay a launch. (example)

 

[Blackhawk]

Blackhawk posted whilst I was writing, but brings up a point of heartburn for me. People not going on the flight make a go decision, very poor in my opinion. Management types making a no go decision, cool, telling the crew to go when there is elevated risk, bad.

Obviously there is a difference between military and civilian side and the risks assumed. My point about management on the civilian side was not that they could force a mission that the pilot felt was too risky, but if the risk assessment reached a certain point the pilot could NOT undertake the mission unless it was approved by management. On the military side I know there were times when the risk reached a certain level that commanders cancelled the mission. There were other times when the mission was bumped up to a general officer who approved the mission. As Mike pointed out the condition of the patient is the cross dressing uncle no one wishes to discuss.

 

[Blackhawk]

At what level were MAST mission approvals made?

Medivac was separate from what I did- assault, ash and trash. I assume they were much like us. At a certain level my company commander could approve a mission. Another level, got bumped to the BC. If I remember correctly any time we crossed the berm into Iraq the first O-6 had to approve the mission- I don't think any were ever cancelled, they just had to be aware of them. At a certain level a GO had to approve missions. I seem to remember a few of mine being approved by GOs.

 

[MikeD]

I'm not saying the med crew has no vested interest. If the med crew and medical mgmt don't trust or give the pilots the tools to make competent go/no-go decisions, this isn't a CRM problem. I am, of course, playing from the side that the pilots are competent professionals and that the med crew, while having good intentions, simple do not possess the knowledge or experience to make a quality go/no-go decision, and I am talking from a fixed wing side. Being a nervous flyer around T-Storms is not a reason to cancel or delay a launch. (example)

You are intertwining actual operation of the aircraft itself, and whether the mission goes or not at all. They're two VERY different things.

It's not so much that the med crew would say "yes" to going on a mission when the pilot says "no"; it's more of the med crew having the ability to say "no" on the mission when the pilot says "yes". In that vein, if they're uncomfortable for whatever reason, then the mission doesn't go. Go/no go decisions are part of CRM.....it's not just control of the aircraft itself that is.

Plus, fixed-wing side is VERY different from rotary wing side.......like Earth and Mars different; in terms of hazards, etc. Generally speaking, you guys have it far easier, as you are doing "interfacility transfer" work, vice the guys doing the "911 ambulance work" on the rotary wing side. Not a hit or slam on anything, just the reality of the situation.

 

[Dugie8]

Oh, I get the FW vs RW difference. Don't get me wrong, a med crew member will never make a go decision when I say no. I am also not saying I would blow off a no go decision by a med crew but I do need some authority as the PIC to say yes the flight is safe even if a nurse doesn't want to go, without it being a "step on the toes" thing. Someone is free to remove themselves from the flight and should be able to without retribution, but the mission should not suffer because of "fears".

I see the ugly side of this and maybe I am too cynical, but I see med crew wanting to bag a flight for "buzz word" reasons, i.e. TS, ice, wind, etc when in reality it is just a game to get the flight delayed or cancelled because they don't want to "work" at that particular time. To put another way, a med team member has never beaten me to the no-go decision, I have made that decision long before they make it to the hangar.

 

[Dugie8]

Obviously there is a difference between military and civilian side and the risks assumed. My point about management on the civilian side was not that they could force a mission that the pilot felt was too risky, but if the risk assessment reached a certain point the pilot could NOT undertake the mission unless it was approved by management. On the military side I know there were times when the risk reached a certain level that commanders cancelled the mission. There were other times when the mission was bumped up to a general officer who approved the mission. As Mike pointed out the condition of the patient is the cross dressing uncle no one wishes to discuss.

You're talking about risk assessment. Lets look at this from a realistic point of view. Somebody has come up a list of risk factors and assigned numerical values to them. As PIC if I add those factors up and the value is over a certain amount I am supposed to call someone, who is not on the flight, and get approval. In the real world, where revenue is king, how many people are going to look at the value and make a no-go decision? Assuming there is no way to mitigate/eliminate the risk. This is the ultimate in pilot pushing, in a passive way. If the risk amount can be mitigated by simply making a phone call and someone (again, my theme here) NOT ON THE FLIGHT can make the go decision, what is the point? Take a look at any risk assessment list, this is stuff competent pilots consider for every flight. The numerical value of it means nothing to a pilot, it is just something to put on a form.

This may make it seem like I am "anti safety" or an authority hog, nothing could be farther from the truth. I want the the authority to say no and not have it trumped by a form or a medic or a manager. I need the authority and trust of everyone to say yes and have the backing that, if someone doesn't want to go they are free to remove themselves and be replaced with the replacement being 100% informed and in agreement that the flight is safe, without it being a wee wee swinging contest. It gets forgotten that I am not only responsible for the medics, I am responsible for the patient as well.

 

[MikeD]

Oh, I get the FW vs RW difference. Don't get me wrong, a med crew member will never make a go decision when I say no. I am also not saying I would blow off a no go decision by a med crew but I do need some authority as the PIC to say yes the flight is safe even if a nurse doesn't want to go, without it being a "step on the toes" thing. Someone is free to remove themselves from the flight and should be able to without retribution, but the mission should not suffer because of "fears".

I see the ugly side of this and maybe I am too cynical, but I see med crew wanting to bag a flight for "buzz word" reasons, i.e. TS, ice, wind, etc when in reality it is just a game to get the flight delayed or cancelled because they don't want to "work" at that particular time. To put another way, a med team member has never beaten me to the no-go decision, I have made that decision long before they make it to the hangar.

Also, let me emphasize too that I see where you're coming from and agree on your main points:

- you don't need backseat drivers telling you how to fly the plane who aren't pilots
- you are paid, qualified and hired to be using judgement and making professional decisions regarding safety of flight and mission go/no-go.
- you shouldn't have external pressures, positive or negative, influencing that good judgement.

Im fully with you on those. I too think that ground management shouldn't drive things either way. Where this becomes a bit more vague between "how things should be" vs "how they sometimes are", is when dealing with the med crew. We both know that while the med crew isn't the "flight crew", in terms of the actual operation of the aircraft, the fact that they are "mission crew", in terms of being onboard and being more than just pax......there's a certain balance that needs to be made at times. It can be easy, and it can sometimes be tricky, dependent on exactly what you cite: personalities.

To be completely fair, you view isn't cynicism, it's actual reality of the facts of some EMS operations out there that pilots have to deal with. I too agree that if someone doesn't want to go on a mission that you determine is safe, that they should be able to be replaced, but some operators either don't allow that, or don't have the personnel luxury in availability. More often, the problem appears to be med wanting to go, and the pilot saying no; which should be cut and dried...no question. And on the flip side, if someone's motive for not wanting to go is because they don't want to work at that time.....and they're trying to pull the safety card to do it; that's a complete foul.

But in normal circumstances, any concerns of the med crew on the flight safety should be able to be addressed by the pilot satisfactorially; barring any hidden agendas on either side......ie- mission oriented pilot who wants to go at all costs, or lazy med crew who doesn't want to work; or even vice versa.

 

[Dugie8]

Very good, I glad I'm not completely bat guano crazy. To be fair, the amount of drama I have had to deal with has been very minor, I do have a fear however, that too much "power" shifted one way or the other can severely undermine an operation and that very clear line of distinction of responsibilities and authority needs to be there from the top down.

 

[Blackhawk]

You're talking about risk assessment. Lets look at this from a realistic point of view. Somebody has come up a list of risk factors and assigned numerical values to them. As PIC if I add those factors up and the value is over a certain amount I am supposed to call someone, who is not on the flight, and get approval. In the real world, where revenue is king, how many people are going to look at the value and make a no-go decision? Assuming there is no way to mitigate/eliminate the risk. This is the ultimate in pilot pushing, in a passive way. If the risk amount can be mitigated by simply making a phone call and someone (again, my theme here) NOT ON THE FLIGHT can make the go decision, what is the point? Take a look at any risk assessment list, this is stuff competent pilots consider for every flight. The numerical value of it means nothing to a pilot, it is just something to put on a form.

This may make it seem like I am "anti safety" or an authority hog, nothing could be farther from the truth. I want the the authority to say no and not have it trumped by a form or a medic or a manager. I need the authority and trust of everyone to say yes and have the backing that, if someone doesn't want to go they are free to remove themselves and be replaced with the replacement being 100% informed and in agreement that the flight is safe, without it being a wee wee swinging contest. It gets forgotten that I am not only responsible for the medics, I am responsible for the patient as well.

First you are making the false assumption based upon your leftist public school indoctrination that a corporate suit only wants the aircraft to fly to bring in revenue and they do not care about the lives of their employees or the patients. Even if that were the case (most unlikely), what will the bottom line look like if a multi-million dollar helicopter leaves a smoking hole in the ground killing 3+ crew members and a patient? In any business or life decision there is risk analysis and much of it entails $$$. Killing patients and opening the company to possible chapter 11 level liability is a risk. As a PIC I may determine the risk is acceptable. Heck, I have kids and if I see that a child NEEDS the transportation I will undertake risks I would not otherwise take. Frankly, I think most MEDIVAC crews would do this, would risk their lives for the life of a child. In those situations it may take the intervention of someone in a leadership position to step in and say "No".
I dealt with this on a continuous basis- leaders who were not on the flights cancelling missions. Sometimes they were the only ones detached enough emotionally from the mission to make the rational and correct decision.

 

[MikeD]

Sometimes they were the only ones detached enough emotionally from the mission to make the rational and correct decision.

I do know of a few EMS operators that have had policies of having the pilot/flight crew not made aware of specific patient demographics or injuries, so as to not have a go/no-go decision influenced in any way by that information.

 

[Blackhawk]

I do know of a few EMS operators that have had policies of having the pilot/flight crew not made aware of specific patient demographics or injuries, so as to not have a go/no-go decision influenced in any way by that information.

I don't know if that is or is not the right call- probably is. As we discussed I don't know that I would say it should have no impact. Should you do a night landing next to an interstate for someone who is not critical? I know on the military side MEDIVAC was not called in every time someone was hurt- not worth the cost/risk. On the flip side I know some MEDIVAC pilots who demonstrated extraordinary bravery picking up critically wounded soldiers under fire. Was the life of that soldier(s) worth the risk of an expensive aircraft and crew? I'm honestly not asking that as a rhetorical question. I know it is a question commanders often struggled to answer.
Civilian side obviously there is a different level of risk acceptance. But as a society will we accept the risk of the civilian MEDIVAC crew in certain situations, much as we accept the risk fire fighters assume? You probably have good experience on that side, where fire fighters want to keep fighting but the chief calls them off as the risk is too great. Yet there are other times the chief assumes the responsibility for the risk in a dangerous situation as lives are involved.
I don't think management should be able to force a flight where someone on site determines the risks are too great, but there probably should be a point where a flight crew can not make the decision to go without authorization from higher up. Also with the cost of helicopter flights and the possible risks involved I'm not sure it should be used where ground transportation suffices.