Association of Air Medical
Services
and
CORE Industry
Safety Committees
Position Statements
Published by
Association of Air Medical Services
526 King Street
Suite 415
Alexandria, VA 22314-3143
(703) 836-8732 phone
(703) 836-8920 fax
www. aarns org
2003 Edition
Copyright © 2000
Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
Association of Air Medical Services
and
CORE Industry
Safety Committees
Position Statements
Table of Contents
Safety within an Air Medical Program 2
Improving Safety through the Establishment of a Safety Based Culture 4
Appropriate Flight Crew Scheduling and Provision for Adequate Rest 7
Improved Flight Safety through Crew Member Interaction (CRM)
with Pilot in Command 10
Personal Protective Equipment for Flight Crew Members 13
Flight Crew Refusal to Participate in a flight as a Result of Concern
for Personal Safety 19
Special Programs designed to Improve the Flight Team Members’
Physical and Mental Well Being 21
The Role of the Communications Center in Enhancing Air Medical Safety 23
Safety Consideration for the Combative or Potentially Combative Patient 26
Loading and Unloading of Patients with the Aircraft Rotors Turning 28
Aircraft Emergencies 29
Weapons of Mass Effect 30
Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
SAFETY WITHIN AN AIR MEDICAL PROGRAM
Problem Statement:
Air medical accidents continue to occur despite efforts to improve safety within the air medical industry.
Significance:
The use of helicopters and fixed wing aircraft to transport patients is a recognized part of the health care system in the US as well as several countries around the globe.
EMS helicopters are twice as likely to be involved in a reportable crash and four times as likely to involve fatalities as were all helicopters operated under FAR Part I 35.
Helicopters and airplanes used in EMS require extensive modification to accommodate the medical equipment on board the aircraft for patient care. In case of an aircraft accident, these modifications may contribute to occupant injury and death.
As an industry, we must continue to pursue opportunities to minimize the risks associated with air medical transport for our pilots, crewmembers and patients.
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Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
Bibliography
1. Dodd, R. (1992). Factors Related to Occupant Crash Survival in Emergency Medical Service Helicopters. Dissertation John Hopkins University/Aviation Science and Technology.
Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
IMPROVING SAFETY THROUGH THE ESTABLISHMENT OF A SAFETY-BASED
CULTURE
Background:
A safety-based culture is defined by everyone feeling a responsibility for safety and pursues safety improvement opportunities on a daily basis (1). A safety-based culture provides the framework for the safety program for any air medical service.
Recommendations:
Paradigm Shifts for a Safety-Based Culture
“In order to exceed current levels in safety excellence and reach the goal of a safety-based culture, there needs to be changes in behavior, attitudes and perception — a true paradigm shift for total safety. These shifts require new principles, approaches and procedures and will result in different behaviors and attitudes among the entire team, from top management to hourly staff. An added benefit will be a sense of empowerment and consequently, support throughout the entire culture”(l).
The ten changes are:
From Government Regulations to Corporate Responsibility
From Failure Oriented to Achievement Oriented
From Outcome Focused to Behavior Focused
From Top-Down Control to Bottom-Up Involvement
From individualism to Team Work
From a Piecemeal to a Systems Approach
From a Fault-finding to Fact-finding
From Reactive to Proactive
From Quick Fix to Continuous Improvement
From Priority to Value (2).
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Association of Air Medical Services
& CORE Industry Safety Committee
Safety Position Paper 2000
As an outgrowth of a safety-based culture, human factors associated with air medical transport need be a day-to-day focus for all members of the air medical transport team and support staff. Initial and annual training in the various aspects of human factors should be required of all team members (administration, pilots, mechanics, communications and medical crews).
Creating A Safety Committee:
A Safety Committee is a part of every air medical program and can contribute to the development of a safety-based culture. The air medical program’s safety committee, when applicable, must be a partnership between the aviation operator and the program/hospital.
The Safety Committee should be aware of industry trends for safety enhancement including professional organizations’ efforts to address safety standards for their membership. The Safety Committee should be empowered to develop policies and make recommendations for safety enhancement to include but not be limited to:
Develop and communicate a Safety Mission Statement
Create an Education and Training Process
Develop Evaluation Procedures
Contribute to a Performance Feedback Mechanism
Continuous Quality Improvement as it Pertains to Safety
Association Position:
The Air Medical Program leadership has a responsibility to develop a safety-focused culture by identifying and implementing the essential elements of a safety culture and by developing and empowering a safety committee.
Association of Air Medical Services
& CORE Industry Safety Committee
Safety Position Paper 2000
References
1. Dickinson, L. (1998). Creating a Safety Based Culture. AAMS Medical Transport Leadership Institute, Topic 110.
2. Dodd, R. (1992). Factors Related to Occupant Crash Survival in Emergency Medical Service Helicopters. Dissertation John Hopkins University/Aviation Science and Technology.
APPROPRIATE FLIGHT CREW SCHEDULING AND PROVISION FOR ADEQUATE
REST
Background
Many fatigue countermeasures have been proposed. To date, only one approach — improved work schedule systems — has proven to provide positive long-term effects. Improved work schedule systems recognize that cultural, social, individual, and chrono-biological factors must all be considered in the design of a scheduling system. Such a system requires cooperation and active participation between workers and the organization(s) (1). Chrono-biologists have shown that in order to maximize performance, shifts should be changed infrequently, in a forward-rotating direction (i.e. from day to evening to night), with days off scheduled so as to allow maximum transition between shifts (2).
The National Transportation Safety Board (NTSB) has published a safety study that clearly documents a relationship between performance levels and adequate rest. Alertness, fine motor skills, and judgment deteriorate significantly when adequate rest is not obtained (3). (Adequate fluids and nutrition are also required for optimal performance) (4). Prior to the institution in the mid-80’s of Federal Aviation Administration (FAA) regulations mandating pilots receive a minimum of eight to ten (8-1 0) hours of uninterrupted rest within a 24-hour period, the air medical transport industry suffered its worst year ever with regard to EMS incidents/crashes. Most of the accidents involved fatalities (5). After the minimum rest statutes were implemented, the accident rate declined sharply. While these Federal Aviation Regulation (FAR) requirements under Part I 35 apply only to pilots and not to other air medical transport crewmembers, it is common sense that safety will be enhanced if every single member of the transport team is adequately rested. To provide for maximum safety and job performance, non-pilot crewmembers should receive a minimum of eight hours uninterrupted rest within every 24-hour period during peak transport seasons and six hours interrupted rest during slow transport seasons. These 24-hour periods include on-call time as well as actual on-duty time.
According to the National EMS Pilots Association Safety Guidelines, “. . . fatigue cannot always be self-determined, and in most cases it may not be apparent until serious errors are made . . .“ (6). Therefore, in order to demonstrate a paradigm shift of being ‘proactive rather than reactive’, scheduling must allow for no less than these minimums of rest periods.
Recommendation
The Association of Air Medical Services recommends that all flight programs recognize that fatigue compromises safe decision-making. Programs must realize the importance of adequate rest and enforce procedures, which through a proactive stance promotes appropriate scheduling.
Association Position:
A written policy should be established so that fatigued personnel can be removed from service, and/or back-up personnel identified to assume flight duty should a crew member become excessively fatigued or otherwise unable to perform optimally at any time.
Association ofAir Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
References
1. Tepas, DI. and Monk, TM. (1987)Workschedules. In: HandbookofHuman Factors, G. Salvendy, (Ed.). New York: John Wiley & Sons.
2. National Flight Nurses Association — Position Statement: “Improving safety in the air-medical helicopterenvironmenf’. Issue 1, 1998.
3. National Transportation Safety Board, Dodd R.S. : Safety Study, commercial emergency medical services helicopter operations. U. S. Department of Commerce, National Technical Information Service. January, 1988, Report #NTSB/SS-8801.
4. Rayman R.B.: Passenger safety, health, and comfort: a review. Aviation Space & Environment Medicine. 1997; 68 (5) 432-40.
5. North, Michelle. Rocky Mountain Helicopters Online. White Papers: EMS crew interactive roles; pilot and flight nurse. 1997.
6. National EMS Pilots Association Safety Guidelines. In: National Flight Nurses Association — Position Statement: “Improving safety in the air-medical helicopter environment’~ Issue 1. 1998.
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Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
Bibliography
Cauthorne CV., Fedorowicz, R.J.: EMS Helicopter Pilots and TheirWork Schedules: an Analysis. Hospital Aviation I 986; March: 1 8-24.
Collett H.M.: Air Medical Accident Rates. JournalofAirMedical Transport 1991; 10 (2): 14-15. Dodd, R.S. : EMS Helicopter Safety Revisited. Hospital Aviation I 989; 1 : 6-8.
Martin, T. : Adverse Effects of Rotating Schedules on the Circadian Rhythms of Air Medical Crews. Air MedicaiJournal. April—June, 1995: 83-86.
NFNA. Performance Standards, Safety Recommendations. Standards of Flight Nursing Practice, 2ed., 1995. P. 67.
Preston, N.: Air Medical Helicopter Accident Rates. Journal of Air Medical Transport. 1992; 11(2): 14 -
16.
Wright, D.: Safety Management vs. Picking Leaves. Journal of Air Medical Transport. 1991; 10 (9): 11-2.
Wright, D.: An Analysis of Shift Work and Emergency Medical Service Helicopter Pilot Performance:
Unpublished Manuscript, 1984.
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Association ofAir Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
IMPROVED FLIGHT SAFETY THROUGH CREW MEMBER INTERACTION (CRM)
WITH PILOT IN COMMAND
Background:
The paradigm shift from individualism to teamwork requires an “entire-crew-oriented” approach to creating and maintaining a safe environment for air medical transport. In Practice Standards for Flight Nursing, the standards of professional performance for flight nurses are: ‘safe transport of the client and others during transport, as well as, (participating) in the safety ofthe aircraft and all others aboard the aircraft (1). It is well recognized that all air medical crewmembers, in cooperative efforts with the pilot in command, play an important role in assuring a safe aviation environment. Subsequently, Crew Resource Management (CRM) must be a CORE VALUE (rather than a mere priority) of EVERY air medical program.
After the unacceptable accident rate (of a high as 13.4 accidents per 100,000 hours — most resulting in fatalities) of the early 80’s, the air medical industry attempted every possible course of action to reduce this high rate. Notably, the highest percentage of accidents were a result of some human factor or error, and it was determined that, somehow, there had to be developed interaction between all crewmembers and the pilot. The medical aircrew is a team and must work together helping each other to do the best job possible for the team rather than working separately as an individual (2).
Recommendations:
It is believed that effective teamwork and communication between crewmembers will ‘save more lives than Nomex or helmets’ (3). This communication should include pre-mission and/or shift briefings, pre-flight checklists, post-mission briefings, and minimum requirement of annual safety training, to include education and practice of appropriate actions during an aircraft emergency (4). Data identified in the usually more formal and written post-mission briefings should serve as a basis for identifying potential problems and monitoring trends. This information should include feedback from all crewmembers involved in the particular mission, (including dispatch personnel), and should not be used as a punitive measure.
According to results of two surveys conducted by the National Flight Nurses Association, 32% of respondents in 1988 and 60% ofthel998 respondents practiced CRM in their programs, while 62% in 1988 and 71 % in I 998 had written policies addressing such (5). If doing all in our power to ensure a safe aviaUon environment is truly a core value, we understand that pilots are no longer solely responsible for creating this safe environment, and therefore, these statistics must become 100% industry-wide!
Association Position:
. All air medical team members should receive training in Crew Resource Management initially upon hire and at least annually thereafter.
. A policy and practice of conducting pre-mission and/or shift briefings, pre-flight checklists, post-mission briefings with documentation for trending purposes must be in place and tailored to fit each program’s specific needs.
• A minimum requirement of annual safety training, to include education and practice of appropriate actions during an aircraft emergency should also be in place.
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Association ofAir Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
References
I . National Flight Nurses Association. Performance Standards, Safety Recommendations. Standards ofFlight Nursing Practice, 2 ed., 1995. P. 67.
2. North, Michelle. Rocky Mountain Helicopters Online. White Papers: EMS crew Interactive roles:
pilot and flight nurse. I 997.
3. AAMS & CORE Industry Safety Committee Members at 1998 Air Medical Transport Conference, Safety Committee Meeting. Albuquerque, New Mexico; October, 1998.
4. National Flight Nurses Association — Position Statement: “Improving safety in the air-medical helicopterenvironment” Issue 1. 1998.
5. National Flight Nurses Association — Safety Survey. In: Position Statement; “Improving safety in the air-medical helicopter environmenf’: Appendix B, 1998.
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Association of Air Medical Services & CORE Industry Safety Committee
Safety Position Paper 2000
Bibliography
CAMTS. Commission on Accreditation of Medical Transport Systems. Accreditation Standards, 3rd ed., 1997.
Collett HM: Air medical accident rates. Journal ofAir Medical Transport, 1991; 10 (2): 14-15.