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By David Carr
Director of Safety


Practical Drift

STOP! Infection

Quick Hits

Recent Incident

2013 Incident Stats

November 17
1999 gave way to November 18
in College Station Texas. Just another cool autumn morning. But
for Texas A&M, this day would prove to be far from normal. Tragically, the University and victims families would
soon have to come to grips with a new term.

-Practical Drift
Polices and procedures (P&P) describe how tasks will be performed and to provide employees with performance
expectations and limits. Over time, many of these P&Ps morph, usually to improve efficiency or because the reason
for establishing the P&P in the first place is forgotten. If youve ever heard a co-worker say Thats only done in
training, this is how we do it here at the base; because of ___ we came up with a work-around; or something to
that effect, chances are that your organization is experiencing some level of Practical Drift.

-The Aggie Tradition
The Texas A&M bonfire tradition began in 1907 as a way to congratulate the football teams win over their arch rival,
the University of Texas. What started out as a burning of a trash pile in simple celebration, ended 92 years later with
the construction of a massive, highly complex and tragically un-engineered log design.

-Practical Drift Timeline

1928 1958 1993
1978: 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 modified
numerous 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 18
, 2:32 am, Practical Drift moved from theory to reality. The stack was
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.

-The Investigation
The 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. Under
their control, the Corps had a very disciplined process of training and passing down design and assembly
methods from one class to the next. Eventually though, participation was expanded to include other
students who hadnt received the education and training needed to operate around, assemble and erect
the stack safely.

There had never been any professional design engineering, only a small notebook with construction
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 secure
the stack, but there had been no periodic evaluation of the impact those changes had on the integrity of the

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

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

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


Josh Smith

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


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

So what does it mean to be cautious and take precautionary measures? The Centers for Disease Control
(CDC) recommends that adults performing jobs where there is risk of exposure, be vaccinated not only for
the well-being of the employee, but also for the well-being of the family member or whoever may come in
close contact with the employee. Family member? Lets return to the above scenariothe person you
forgot about before throwing those old boots and the dirty flight suit on the floor, which has active Influenza
Virus 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. Taking
your work clothes, leather boots and work items off before entering your home is another great way of
being cautious. It has been found that leather absorbs fluid on a microscopic level just as easy as many
fabrics. So, this tells us that the leather boots you wear to work should definitely be left outside of your
home due to the environment we work in and the circumstances in which we do our job. This is particularly
important because certain viruses, such as Hepatitis B, can remain virulent for weeks. Virulence refers to
the organisms ability or strength to overcome the bodys defense mechanisms. It is because of the
virulence factors we must make sure we are cautious and take certain steps to preserve not only our own
well-being, but the well-being of our loved onesand lets not forget about the well-being of future patients
we encounter. Steps to consider following a shift at work:

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

Wash your clothes with a color safe bleach solution. Unless you own a commercial grade washing
machine 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 have
the clothing professionally cleaned or thrown in the biohazard trash rather than placing it in the
same washing machine you use to wash your childrens clothes.

If using a commercial grade disinfectant, allow the chemical to remain on the surface of the object
for 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 recommends
personnel working in the healthcare industry to have a flu vaccine annually. There has been much
controversy about the flu vaccine recently, and there are two sides to every debate, but the CDC
recommends that you have the vaccine unless you are physically unable to take it due to certain
immunological diseases. I recommend you visit the CDCs website at for more
information concerning the Influenza virus prior to making your decision.

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

Measles, Mumps, Rubella
Hepatitis B
Pertussis (T-dap)
Meningococcal Disease


It is to be noted that the list above is recommended by the worlds leaders in infectious disease research.
This is only a sample of the vaccines needed for people in the healthcare industry and for more
information you should visit the CDC website at

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 work
even 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!


With 50+ bases, scattered coast to coast, there are lots of good ideas, and smart folks who could give us good
answers if we would just ask the questions. With this in mind then, we embarked on a novel approach to
developing and implementing policy and procedure changes. Call it, beta testing for our beta testing. You
received 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 is
your chance not only to influence a policy under revision, but to also validate our method for fielding policies. If you
havent read over the policy, it can be found on the Sharepoint Safety Page.
Read it. Discuss it with your peers. Send me comments, suggestions. You have until November 10
. If you dont

Pilots, if you are involved in an aircraft incident or near miss, you have responsibilities. First and foremost is your
responsibility for the safety of people and property entrusted to you. Your second responsibility is to report the
incident. Prompt submittal of an AIOR is required and in many cases, it should be accompanied with a submission
to 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 again.
Following in close trail, your government would also like to know the answers to those same questions. When we
receive an AIOR, we determine whether the incident can be handled internally or whether it needs to be reported to
the FAA. Thats our lane. I highly recommend you follow up your AIOR with a NASA ARC 277b, (NASA report)
to 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 of
cash to get, and hold on to your certificate. So I think a little insurance is a good thing. All submissions are kept in
strict confidence. In all but the most egregious cases, submitting a report before the FAA learns of the event
provides immunity to the reporter against certificate action. When in doubt, report! Aside from taking care of your
backside, ASRS has a HUGE database of de-identified incident reports available in an easy to use searchable
database. If youve never been to it, I highly recommend it. Its a great forum for learning from the mistakes of

When we get our online incident reporting program in place, it will have a link that will take you to the NASA
website to fill out a report. Until then, here it is:



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

I dismounted the goggles from the night pilots helmet
and put them in the carry bag. Upon arrival at the
aircraft I would have normally placed the radio on the
pilot seat and then done the walk around, but because I
had the goggles and had decided to mount them to my
helmet at the sending hospital I went to the copilot door.
I placed the radio on the ground and promptly kicked it
over, I moved the radio and in the process of reaching
into the aircraft I kicked the radio over again. I then
placed the radio on the aircraft step.

The life blanket was in the chin bubble so I refolded it
onto the stretcher, placed the goggles in the aircraft,
then my jacket and hat and closed the door. I then
completed my walk around as did the other two
crewmembers. We completed the stop checklist and
started the mission.

Dispatch called after we had completed hot fuel at the
airport and had flown approximately 15 or 20 minutes
after the first takeoff and asked us to check our
compartments as a radio had fallen off the aircraft.

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

-Hospital LZ Near-Miss-
The landing zone is on the hospital drive with four
lanes entering it. The hospital normally has a security
vehicle blocking one lane with cones on the other
three. On this occasion they were using cones on all
four points.

As we were on short final, one of the crew mentioned
that we were blowing some cones around, which is a
normal occurrence because of their proximity. And
because of large trees around the LZ, visibility is
limited to any traffic that might approach from two
lanes until the very last minute.

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

My concern is that he could have easily turned right,
onto the LZ and drove underneath of us. I talked to the
Security Supervisor and suggested that if they have
limited personnel, that putting chains up might be a

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

The next morning, crew coming on duty found the bag
of clothes that were accidently left on board.
Crewmember called police to report the bag of clothes
into evidence. Police Officer notified DEA and they
came to base to take custody of the evidence. DEA
told crew that a wipe down of the aircraft for a DECON
would be sufficient.

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

No media was involved and DEA was appreciative for
us contacting them and providing the evidence needed
for their investigation.

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:

Director of Safety
David Carr
The Med-Trans Leadership Team
Chief Operating Officer
Rob Hamilton

Director of Operations
Bert Levesque

VP, Program Operations
Connie Eastlee
Director of Maintenance
Josh Brannon

Chief Pilot
Don Savage

Assistant Chief Pilot
Mike LaMee

VP, Flight Operations
Brian Foster


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