Safety Compass Newsletter 5-2013

8/12/2019 Safety Compass Newsletter 5-2013

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How to Murphy-Proof Your LifeBy David CarrDirector of Safety

May 2013

How to Murphy

Proof your Life

The Commandment

L-A-S-E-R

Pilot Safety Award

2013 Incident Stats

Recent Incident

Summaries

I am sure everyone reading this newsletter has heard ofMurphys Law: if anything can go wrong, it will. Beingn the safety business, Ive seen Murphys Law wreakhavoc on a pretty consistent basis so when I think ofMurphy, I cant help but picture this guy:

In the title, I used Life because Murphy-Proofing is not limited to the workplace.Sure you dont want Murphy setting up

shop in your aircraft, around your tool-box or beside you as you deliver patient care. Butust as importantly, you dont want Murphy showing upon your front doorstep uninvited either.

On page two of our newsletter, one of our most seniorpilots, a man with decades of professional experiencedetails for us his recent run-in with Murphy. On pagethree, another example. This time from a Metro Aviationpilot who received an unannounced visit from Murphywhile flying at night under night vision goggles.

Our soon to be published Safety Management System

(SMS) manual has a lot to say about Murphy-Proofingunder the section entitled: Risk Management.

Incorporating Risk Management in decision making can

good enough to just come up with risk reducisolutions, you have to use them.

Step 5: Evaluate. Did your control measures work reduce or eliminate the risk? If so, great. If not, thwhat else do you need to do to bring the risk to acceptable level?

To illustrate the process, letsuse Risk Management inpractical exercise. Suppose that you are the parent

this young, happy 16 year oldhappy because she jugot her driverslicense.

Step 1: Identify the risks your inexperienced child wface behind the wheel ofyournew car.

Step 2: Assess those risks. How bad can it be? Whathe likelihood that something bad might happen to hto others, or toyour newcar?

Step 3: Identify control measures. What rules can yput in place to help her concentrate on driving, abeing safe? I can think of at least a dozen.

Step 4: Implement control measures. You made trules, its your car, now you have to enforce them.

Step 5: Evaluate. Are the rules you put in place workto reduce the chance of something bad happening your daughteror your new car?

ThatsRisk Management. Of course my kid wouldnt

driving my new car in the first place (Murphy-Proofiperfected). The Risk Management process works as wfor a 16 year old driver as it does in flying, maintainiaircraft or providing medical care, not to mention in yopersonal life, finances, relationships etc.

Embrace Risk Management because on that proverbdark and stormy night when you really need everythito line up perfectly, you dont want this guy ridishotgun.

go a long way to preventMurphy from mucking things up.Here is a Risk Management toolthat is both simple and effective:

Step 1: Identify the risks in youroperation, big and small;

Step 2: Assess the risks. How

severe can they be, and what isthe probability of them having anegative impact?

Step3: Identify control measures.Control measures are nothing more

that things you put in place to

reduce or eliminate the risk from

hurting you or crumpling metal.

Step 4: Implement the controlmeasures. A great plan without

execution is useless. Itsnot


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MAY 201

asked if there were any FADEC caution lights and if thwere any exceedances. I told him that everythappeared normal. He walked me through the FADmaintenance check. According to the lights, the FADhad not logged any irregularities. He also stated thatcouldn't be sure if anything was logged unless he hooup a computer to the ECU. However, with information available, he didn't see any reason I shonot complete the flight. I took the patient to receiving hospital. Got fuel at the airport and returnedbase. Upon arrival the mechanic met me at the helipand hooked the computer to the ECU. He discoveredexceedance of 117.4% of torque for 0.10 sec. The aircwas grounded and I considered resigning. Aconsulting with the base manager, the regional amanager, the chief pilot, the maintenance director, quality assurance guru, bell technicians, Rolls Roengine experts and God, it was determined that th

was NOTan over torque. In retrospect, it all could hbeen avoided if I had just used the checklist, readeach item and making visual checks.

God gave Moses the Ten Commandments. That is wthey are, Commandments, we violate them at our orisk. The Chief pilot of Med-Trans also gives commandments, one of which is Use Your Check Lis

L-A-S-E-R

The Federal Aviation Administration is continuing to a dramatic increase in the number of people pointlasers at aircraft in flight. In 2005, 283 laser incidents wreported by pilots. That has exploded to over 2,6002010. "When a pilots eyes are hit by a laser fired fr

the ground, or wherever, first of all it impacts his nivision instantaneously. If it is a very powerful laser it literally blind the pilot," said aviation expert Jay Mi"Some of these exposures have required pilots to havetemporarily give up control of an aircraft to their co-por abort a landing," said former FAA Administrator RaBabbitt.

Anyone see a problem with that statement? You got itMed-Trans, we dont have co-pilots to take control of aircraft if the PIC is blinded. Flight crews are dealing wa new generation of green lasers that are extremely

(contin

.

The Commandment

By Curt Smith

When you were a kid, did you ever go to sit down in achair and have someone pull the chair out from under

you? You ended up sitting on the floor with the otherkids laughing at you. When you went to sit down youexpected the chair to be where it had been. It's asurprise when you end up sitting on the floor. Youreangry and you want to blame someone for moving thechair, but to avoid the embarrassment all you had to dowas hold on to the chair as you sat down. There isnothing difficult about that. So do you blame the kidthat moved your chair or yourself for not noticing thechair had been moved? Unless you wanted to sit onthe floor and be the joke of the day, you should blameyourself. The same is true in the aviation industry. Our

Director of Operations empowers each pilot with theOperational Control of that aircraft. This means thatthe pilot is the final clearing authority for the safeoperation of Med-Trans aircraft. We are supposed tohold on to the chair as we sit down.

The A/C had been in the hanger all night having beenstarted and run by me, the day before. I had shut theaircraft down, closed the throttle, turned the boostpumps off, and made sure everything was turned offbefore exiting the aircraft and putting it in the hanger.The next afternoon I took the helicopter out of thehanger to respond to an accident scene. During the

start sequence, the throttle was rolled against the stopto be sure it was in the closed position. Since we werein a hurry and I expectedthe throttle to be in the Offposition, I failed to visually confirm that it was in theOff position. In reality it was in the flight idle position.I then advanced the throttle until it clicked into the flyposition. Again, I did not visually check the throttleposition assuming it was in flight idle. I initiated thestart sequence while guarding the throttle and the idledetent. The start was normal until the NG reached 60%when the engine began an unexpected sudden andrapid acceleration. I instantly closed the throttle

against the flight idle position thinking it was the cutoff position. As the engine idled at 63% it took a fewseconds for me to realize what had happened. I wassitting on the floor after having the chair pulled outfrom under me. I shut the engine down, turned thebattery off, waited about 30 sec. and turned the batteryon. Everything appeared normal. There were noFADEC caution lights and no "E's" on any gauges. Istarted the engine again. It was a normal start and wedeparted the airport to pickup the patient. Uponarrival, having second thoughts about the initial start, Icalled the mechanic and explained what happened. He


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owerful and relatively inexpensive. For about $10, youan purchase a laser pointer that is strong enough toemporarily blind a pilot from 1200 feet away. Soundske the altitudes we operate at. And even if the laseroesnt hit the pilot directly in the eye, the glare fromhe laser can flashblind him when the beam produces a

lindingly bright glare in the cockpit windscreen.

he box shown below illustrates the hazard to all flightrews, but especially those who fly helicopters becausef the low altitudes typically flown. Even the weakest

aser pointers (5 mW) when pointed at an aircraftockpit at night can be a very serious hazard:

WHAT TO DO IF YOUR AIRCRAFT IS LASED

Dont look at the light!

Maintain or regain control of the aircraft

Interrupt the light by shielding your eyes ormaneuvering the aircraft away from the beam

Turn up cockpit lighting if the glare does notdiminish

Contact ATC and report the incident. If able,provide landmarks or other means to identifythe location to aid law enforcement response

If your vision is degraded to the point that youmust land immediately, declare anemergency and request assistance

o report a laser event, go to the sharepoint Safety page,

lick on Incident Reports folder.

or information on the FAAs Laser safety initiative go to:ttp://www.faa.gov/aircraft/safety/report/laserinfo/

BH4071stQuarter 2013

Human Error: 2

Environmental: 4

Material Failure: 2

Directed Laser 0

2ndQuarter 2013Human Error: 2

Environmental: 0

Material Failure: 2

Directed Laser 0

EC 1351stQuarter 2013

Human Error: 1

Environmental: 1

Material Failure: 1

Directed Laser 1

2ndQuarter 2013Human Error: 1

Environmental: 3

Material Failure: 1

Directed Laser 0

MAY 2013

Metro Aviation Pilot Recognized for Safe

Left to Right:Woody Woodard, PIC, First Flight

Mike Stanberry, President Metro Aviation

Metro Aviation recently recognized Joseph WooWoodard, Lead pilot for the First Flight programMelbourne Florida for his exceptional skill in maintaincontrol of an aircraft during an in-flight emergency.

In February 2013, Woodard was Pilot in Command of Health First EC135 on a night flight when seven dustruck the aircraft. The helicopter was sent into a hand dive, and Woodard was left without sight dueone of the birds hitting him between the eyes, effectivtearing off his Night Vision Goggles. Ducks brthrough several windows including the windscreen one landed in the pilots lap. With a broken nose, cand contusions from flying plexiglass, Woodard was ato regain control of the aircraft and make a succesemergency landing at a nearby hospital.

Its hard to train for something like this, but the medcrew did a good job to keep a calm environment, s

Woodard. Mr. Woodard has been with Metro Aviatsince 1985.

According to the FAA, more than 9,500 bird striare reported each year. Med-Trans crews hexperienced three bird strikes so far within the lasmonths. Keep your head on a swivel and use y

helmet visor--Thats effective Risk Management
http://www.faa.gov/aircraft/safety/report/laserinfo/http://www.faa.gov/aircraft/safety/report/laserinfo/http://www.faa.gov/aircraft/safety/report/laserinfo/


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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.

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 li

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 CarrDirector of Safety

MAY 201

B-407

During transport into the hangar, saddle of Heliporterdamaged aft crosstube requiring replacement of tube.Human Error cost: $3,500 (est).

After mission completion, the NG Gauge brightnesswould not respond to instrument lighting rheostat. Allother gauge lights were operating normally. After

attempting to troubleshoot with the rheostat, the pilottapped the edge of the NG gauge and the IR filtercracked. (note: this sounds pretty harmless, but IRfilters are expensive. Estimated cost to replace: $800+)

Ec-135

While in cruise flight at 4500MSL, bird struck right side

of co-pilots windscreen. No damage done, except thatthere is one less bird to hit in the future.

Crew and patient were offloaded at hospital. Thethrough flight inspection was completed and the cabinarea was checked for security of equipment. Pilotcompleted a walk around and departed the hospital padfor fuel. While enroute, a cabin door came open at at50-60 knots. After landing the pilot inspected the door,cabin area and the reminder of the aircraft. No damagewas noted and no equipment or gear was missing. Pilot

acknowledged that he failed to assure the cabin doorhandle was firmly into the closed position prior to liftoff.

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]

AND FINALLY,With spring upon us, you might be itching to get outsand start trimming. May I suggest you benefit from texperience (or mishaps) of others...
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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Safety Compass Newsletter 5-2013