safety compass newsletter 11-2013

8/12/2019 Safety Compass Newsletter 11-2013

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TRADITIONMEET PRACTICAL DRIFTBy David CarrDirector of Safety

NOVEMBER 2013

TraditionMeet

Practical Drift

STOP! Infection

Control

Quick Hits

Recent Incident

Summaries

013 Incident Stats

November 17th1999 gave way to November 18 thin College Station Texas. Just another cool autumn morning.

or Texas A&M, this day would prove to be far from normal. Tragically, the University and victims families wo

soon have to come to grips with a new term.

Practical DriftPolices and procedures (P&P) describe how tasks will be performed and to provide employees with performan

expectations and limits. Over time, many of these P&Ps morph, usually to improve efficiency or because the reas

or establishing the P&P in the first place is forgotten. If youve ever heard a co-worker say Thats only done

raining, this is how we do it here at the base ; because of ___ we came up with a work-around; or something

hat effect, chances are that your organization is experiencing some level of Practical Drift.

The Aggie TraditionThe Texas A&M bonfire tradition began in 1907 as a way to congratulate the football teams win over their arch ri

he University of Texas. What started out as a burning of a trash pile in simple celebration, ended 92 years later w

he construction of a massive, highly complex and tragically un-engineered log design.

Practical Drift Timeline

928 1958 19931978: The traditional design was changed from a stable tee-pee shape to a layered

wedding cake design. Over the succeeding years, the wedding cake design was modifiednumerous times resulting in the log stack being constructed in an ever decreasing inward

cant angle (logs stacked more vertically) making the tower less and less stable. Every year

the stack was being constructed more vertically than the year before.

1994: The first red flag appeared. Heavy rains soaked the ground making the foundation

for the stack unstable resulting in its collapse just days before it was scheduled to burn.

Fortunately, no one was close enough to be injured in the avalanche.

1999: November 18th, 2:32 am, Practical Driftmoved from theory to reality. The stack wa

near completion; 5,000 logs, soaring to over 40ft high. With 58 students working on and

around it, the structure collapsed, crushing 12 to death and wounding 27, many critically.


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The InvestigationThe resulting investigation revealed:

(not a complete list)

For the first 70 years, the Corps of Cadets had been responsible for every facet of the construction. Unde

their control, the Corps had a very disciplined process of training and passing down design and assemb

methods from one class to the next. Eventually though, participation was expanded to include othe

students who hadnt received the education and training needed to operate around, assemble and ere

the stack safely.

There had never been any professional design engineering, only a small notebook with constructio

information, which had been modified over the years and handed down from one generation of college

bonfire builders to the next.

Over time, changes had been made to the shape, location, type of logs used, and the wire used to securthe stack, but there had been no periodic evaluation of the impact those changes had on the integrity of th

construction.

Its Not The Fall That Kills You, Its The Sudden Stop t the BottomLike other things, Practical Drifthappens. When you have a company composed of Type-A individuals, there is aemphasis from management and a natural inclination from employees to continuously improve efficiency, cthrough red tape and get the job doneto improvise when necessary. Being creative is good, efficient ancompetitively necessary but: what are the basic rules that are non-negotiable?And if there is an emergency that requires immediate improvisation for the greatergood, how are those risks identified and reduced?

Think of our policies and procedures as a wilderness trail, snaking up the side ofa mountain. You might be able to move left to pass a slower vehicle, you might beable to pull off to the right to let others pass, but know where the edges are. Andmost importantly, be aware that techniques employed to accomplish the task athand over time are susceptible topractical drift.

If our policies and procedures are too constraining, dont address the risk, or areunrealistic, speak up so they can be re-evaluated. But unless they are changed,consider them as your left and right limits that prevent Practical Driftfromfrom resulting in hurt people and broken stuff.

STOP! INFECTION CONTROL

Josh SmithBS, NREMTP

As you enter your home you can only think about your own bed, because in some sort of magical way you actualheard it calling your name during your drive from work. And, as usual, you kick off your boots, drop the flight suon the floor and head straight toward the shower. Finally, time for sleepthe dirty clothes can wait!

NOVEMBER


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Does the above scenario sound familiar? Unfortunately, this hits close to home for many of us whdedicate our lives to the well-being of others. This is done without hesitation, but it often means we negleour own well-being in doing so. If you are not taking steps to be cautious, and take precautionameasures, infection will catch up to you!

So what does it mean to be cautious and take precautionary measures? The Centers for Disease ContrCDC) recommends that adults performing jobs where there is risk of exposure, be vaccinated not only fhe well-being of the employee, but also for the well-being of the family member or whoever may come close contact with the employee. Family member? Lets return to the above scenariothe person yoforgot about before throwing those old boots and the dirty flight suit on the floor, which has active InfluenzVirus and Hepatitis B Virus attached to it, is your three year old son. Do I have your attention, now?

Being cautious means doing simple things like washing hands vigorously with soap and water. Takinyour work clothes, leather boots and work items off before entering your home is another great way being cautious. It has been found that leather absorbs fluid on a microscopic level just as easy as manfabrics. So, this tells us that the leather boots you wear to work should definitely be left outside of yo

home due to the environment we work in and the circumstances in which we do our job. This is particularmportant because certain viruses, such as Hepatitis B, can remain virulent for weeks. Virulence refers he organisms ability or strength to overcome the bodys defense mechanisms. It is because of thvirulence factors we must make sure we are cautious and take certain steps to preserve not only our owwell-being, but the well-being of our loved onesand lets not forget about the well-being of future patienwe encounter. Steps to consider following a shift at work:

Change clothing and shoes prior to leaving work, if not possible definitely before entering yohome.

Wash your clothes with a color safe bleach solution. Unless you own a commercial grade washingmachine your water does not get hot enough to kill certain viruses.

If clothing is soiled with contaminants such as copious amounts of bodily fluids, it is better to havethe clothing professionally cleaned or thrown in the biohazard trash rather than placing it in thsame washing machine you use to wash your childrensclothes.

If using a commercial grade disinfectant, allow the chemical to remain on the surface of the objefor the recommended time labeled on the bottle. If not the infectious organisms may not be killed.

So what about vaccines? Vaccines have been proven to be very beneficial. The CDC recommendpersonnel working in the healthcare industry to have a flu vaccine annually. There has been muccontroversy about the flu vaccine recently, and there are two sides to every debate, but the CDrecommends that you have the vaccine unless you are physically unable to take it due to certa

mmunological diseases. I recommend you visit the CDCs website at http://www.cdc.gov/flu/index.htm for monformation concerning the Influenza virus prior to making your decision.

The following is a list of vaccines the CDC recommends for healthcare workers.

Influenza

Measles, Mumps, Rubella

Hepatitis B

Pertussis (T-dap)

Meningococcal Disease

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http://www.cdc.gov/flu/index.htmhttp://www.cdc.gov/flu/index.htmhttp://www.cdc.gov/flu/index.htm


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It is to be noted that the list above is recommended by the worlds leaders in infectious disease researchThis is only a sample of the vaccines needed for people in the healthcare industry and for moreinformation you should visit the CDC website atwww.CDC.gov.

As I close, I ask that each and every one of my colleagues reading this go the extra mile and think long

and hard about the health of everyone they come in contact with. Remember, you train hard and workeven harder to ensure the well-being and health of our patients lives, but dont forget that your own well -being is of the most importance. If we dont take care of ourselves, we cant help others!

BETA TESTING OUR BETA TESTING

With 50+ bases, scattered coast to coast, there are lots of good ideas, and smart folks who could give us gooanswers if we would just ask the questions. With this in mind then, we embarked on a novel approach developing and implementing policy and procedure changes. Call it, beta testing for our beta testing. Yoreceived an email very recently concerning a proposed policy change: Aircraft Final Walk-Around Inspection

Think of it like this: If you didnt vote, then you shouldnt complain about who is elected. Same goes here. Now your chance not only to influence a policy under revision, but to also validate our method for fielding policies. If yohavent read over the policy, it can be found on the Sharepoint Safety Page. https://sharepoint.med-trans.net/Safety/default.asRead it. Discuss it with your peers. Send me comments, suggestions. You have until November 10th. If you donvote

Pilots, if you are involved in an aircraft incident or near miss, you have responsibilities. First and foremost is yoresponsibility for the safety of people and property entrusted to you. Your second responsibility is to report thincident. Prompt submittal of an AIOR is required and in many cases, it should be accompanied with a submissioto the Aviation Safety Reporting System (ASRS).

We need to know what happened, why it happened, and what can be done to prevent it from happening againFollowing in close trail, your government would also like to know the answers to those same questions. When wreceive an AIOR, we determine whether the incident can be handled internally or whether it needs to be reported the FAA. Thats our lane. I highly recommend you follow up your AIOR with a NASA ARC 277b, (NASA reporto ASRS, thats your lane.

Ive never met a pilot who got his ratings by sleeping at a Holiday Inn Express. It took you years, and plenty cash to get, and hold on to your certificate. So I think a little insurance is a good thing. All submissions are kept strict confidence. In all but the most egregious cases, submitting a report before the FAA learns of the eveprovides immunity to the reporter against certificate action. When in doubt, report! Aside from taking care of yobackside, ASRS has a HUGE database of de-identified incident reports available in an easy to use searchabdatabase. If youve never been to it, I highly recommend it. Its a great forum for learning from the mistakes others. http://asrs.arc.nasa.gov/search/database.html

When we get our online incident reporting program in place, it will have a link that will take you to the NASwebsite to fill out a report. Until then, here it is: https://titan-server.arc.nasa.gov/HTML_ERS/general.html

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http://www.cdc.gov/http://www.cdc.gov/http://www.cdc.gov/https://sharepoint.med-trans.net/Safety/default.aspxhttp://asrs.arc.nasa.gov/search/database.htmlhttp://asrs.arc.nasa.gov/search/database.htmlhttps://titan-server.arc.nasa.gov/HTML_ERS/general.htmlhttps://titan-server.arc.nasa.gov/HTML_ERS/general.htmlhttps://titan-server.arc.nasa.gov/HTML_ERS/general.htmlhttp://asrs.arc.nasa.gov/search/database.htmlhttps://sharepoint.med-trans.net/Safety/default.aspxhttp://www.cdc.gov/


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NOVEMBER

-Tattoo Parlor Receives a Med-Trans Radio-We received a flight request. Weather was acceptable,but according to policy, I would need goggles for thereturn leg.

I dismounted the goggles from the night pilots helmetand put them in the carry bag. Upon arrival at theaircraft I would have normally placed the radio on thepilot seat and then done the walk around, but because Ihad the goggles and had decided to mount them to myhelmet at the sending hospital I went to the copilot door.I placed the radio on the ground and promptly kicked itover, I moved the radio and in the process of reachinginto the aircraft I kicked the radio over again. I thenplaced the radio on the aircraft step.

The life blanket was in the chin bubble so I refolded itonto the stretcher, placed the goggles in the aircraft,then my jacket and hat and closed the door. I thencompleted my walk around as did the other twocrewmembers. We completed the stop checklist andstarted the mission.

Dispatch called after we had completed hot fuel at theairport and had flown approximately 15 or 20 minutes

after the first takeoff and asked us to check ourcompartments as a radio had fallen off the aircraft.

As I landed to check the aircraft I asked if security hadthe radio and was told no a tattoo shop had it about mile East of the hospital. In the end, I couldnt use thegoggles for the return trip any way as we were flyinginto the sunset and I had better viability unaided thanaided. This is a first in 21 years in EMS.

-Hospital LZ Near-Miss-The landing zone is on the hospital drive with lanes entering it. The hospital normally has a secuvehicle blocking one lane with cones on the othree. On this occasion they were using cones onfour points.

As we were on short final, one of the crew mentiothat we were blowing some cones around, which normal occurrence because of their proximity. Abecause of large trees around the LZ, visibilitylimited to any traffic that might approach from lanes until the very last minute.

As I touched down the crew stated that a car drthrough the cones and passed behind us. They that Security flagged him down and was talking him. After shutdown I talked to the officer and he sit happened so fast that he couldnt do a thing abouHe asked the elderly man why he drove through cones and if he saw the helicopter. He said he the cones and the helicopter, but he didnt think it wa problem.

My concern is that he could have easily turned ri

onto the LZ and drove underneath of us. I talked toSecurity Supervisor and suggested that if they hlimited personnel, that putting chains up might bsolution.

-High Flying Patient-Patient transfer flight. Patient was picked up fromER and his clothes were placed in a plastic hospbag and put on the aircraft. Crew learned that patient had been involved in a meth lab explosion.

The next morning, crew coming on duty found the of clothes that were accidently left on boCrewmember called police to report the bag of clotinto evidence. Police Officer notified DEA and tcame to base to take custody of the evidence. Dtold crew that a wipe down of the aircraft for a DECwould be sufficient.

We notified all managers and thoroughly wiped dothe entire aircraft with CAVI wipes, soap and water.

No media was involved and DEA was appreciativeus contacting them and providing the evidence neefor their investigation.


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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

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]

NOVEMBER

The Med-Trans Safety Compass monthly newslette

is one method we have of communicating with every

employee. We want this newsletter to be a forum fofostering a culture of informing and learning.

I welcome your suggestions on topics you would like

to see addressed here. Better yet, send me you

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

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

door is always open.

David Carr

Director of Safety
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safety compass newsletter 11-2013

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