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IT BEGGED THE QUESTION OF “WHAT SIGNS DID WE MISS?” WAS THIS A CASE OF MISDIRECTED MANAGEMENT, POOR TRAINING, CARELESSNESS, EQUIPMENT, CULTURE, OR JUST BLIND FATE?


those lessons learned were for other programs not hers. After all, they had gone fifteen years without an accident and had even been high- lighted on the local television news station for their stellar safety record. They were going to get around to implementing a safety management system soon enough but marketing and financial issues seemed more pressing with the shrinking flight volume. Since they had no formal incident reporting systems there was not really any way to spot trends except for word of mouth.


She


was very comfortable with their safety record and felt that the past accolades somehow protected them from future problems. She tried to avoid pressuring the pilots or medical crews directly but the few subtle and worried comments about declining flight numbers in the hall and a few “pep talks” at team meetings should be having some affect on the teams by now. She did, however, remember watching a few pilots get fired because they just weren’t “team” players or didn’t get along well with a few flight nurses along the way. One particular pilot was just too slow and conscientious and never launched quickly enough for them. Most pilots pushed hard and were pretty rushed to get their twin engine helicopter off the ground in the six minute window.


out a tedious deviation form and chat with the lead pilot.


If they didn’t--they had to fill The lead pilot had been counseled


on several occasions by the operator’s business managers about how important the upcoming contract renewal was and that pleasing the pro- gram management was so very important.


The


business model and the bottom line were driv- ing most of the decisions.


THE AVIATOR: John arrived just barely on time for shift


change the night before. The shift change brief- ing was so hurried that


he actually didn’t


remember whether or not the outgoing pilot had said something about an electrical smell or not. His piloting skills were legendary, at least in his own mind, and surely among his circle of drink- ing buddies. He always felt that “Truly superior pilots are those who use their superior judgment


to avoid those situations where they might have to use their superior skills.” He had managed to get himself into some very tight situations in the past and always extricated himself from a poten- tial embarrassing moment or worse. He was feel- ing a bit irritable and tired but had been there and done that many a time before. He had attempted to get a nap that afternoon but the kids were pretty noisy and he was sure that sleep was what he caught up with on the night shift. He grabbed a candy bar and an energy drink as he left the house as his evening meal. Just prior to leaving the house he had a heated argument with his wife about their spending habits that were mimicking those of the federal government. The hefty new boat payment and the lack of workover opportunities were causing the family budget to go deeper into debt. He had picked up an opportunity to fly some part-time shifts with the local television station and was doing a little flight instruction to supplement their income but it just wasn’t enough.


It didn’t help matters


that there were increasing rumors of more com- pany base closings circulating and flight volumes had been way down since another competing helicopter had been recently placed at a nearby airport within two miles of them. The state did- n’t really have any oversight controlling EMS helicopters so that air ambulance market was just saturated. Most everyone in the field knew that there just wasn’t enough business for both of them. Competition hadn’t been based on safe- ty or quality of service but how many pizzas, gadgets and free gifts a service could provide the agencies and hospitals in the area. Some of area hospitals or EMS agencies would continue to shop around until they could find a helicopter even after weather turn-downs by one operator. John wasn’t concerned about his lack of


sleep or nasty mood because they rarely flew at night in the last few months as the other com- petitor’s helicopter was pulling in those flights because they were a fully instrumented program with night vision goggles.


John’s operator had


their base on the company list for goggles but it was still several months down the road before they would see them. They still did things the


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