MY 2 CENTS WORTH WHERE’S
“Where’s management?” is a question I’m often asked whenever I have been invited (ironically, by an organization’s management) to give a CRM or air medical resource management (AMRM) course. It’s a valid question because I’m not sure management appreciates the vital role they play in the flight safety of their organizations.
I received a message on my professional Facebook page from a concerned flight nurse asking my opinion regarding an incident that happened in her program. She wrote:
I didn’t know where to start looking for guidance about a safety-related incident that happened in our company, so I thought I’d ask you. About a week ago, a flight crew was pulling our helicopter that was sitting on a dolly into the hangar with a tug. The crew stopped for a moment to turn the main rotor blades so they would fit in the tight space. When the tug started pulling again, it lurched and the ship “danced” on the skids and the taillight struck the raised hangar door that no one had noticed was not quite in the fully raised position. Maintenance was called and they fixed the light and examined the tail to ensure there was no other damage, which there wasn’t.
What I wanted to ask you about is, was it fair of management to send the flight nurse home without pay because they’d failed to raise (the door) all the way? This was accidental. The flight nurse was dismissed for the rest of the shift, but worked the following one.
The rest of the crews were angry and demoralized at management’s approach. I approached our director of flight ops about
10 Sep/Oct 2019
this. His point was if the damage had gone unnoticed and they’d taken off, all three would be dead. (Really?) Looking at it from his perspective, I can understand his fear and frustration; his point being if people don’t have their head in the game, they shouldn’t be there.
My concern is, I think the “solution” to the problem is equally dangerous because the director got angry and took it out on the flight nurse; I believe this can actually breed inattention because the fear and discouragement creates an environment where if someone makes a mistake in the future, perhaps they won’t report it after seeing how this incident was handled.
The director of flight operations stated that in his decades in aviation, past incidents were dealt with in a similar manner as a way to send the message of safety so that people see there ARE consequences. He said, “This is how seriously we take safety.” I would like to know your perspective as it really concerns me.
My reply:
Thank you for reaching out and asking for my viewpoint on the incident. You have a right to be concerned. Going on only the information you’ve given me, I feel it was handled inappropriately. I will also say you are 100% correct in your concern about the repercussions of management’s actions, and your assessment of the possible negative consequences of their action to send the flight nurse home. In my opinion, I think your concern is warranted.
Your story highlights why everyone in a flight program, especially management, should have AMRM training because
By Randy Mains MANAGEMENT?
practicing AMRM sensitizes team members (anyone who can have a bearing on the safety of the organization) to realize the consequences of their decisions and their actions or inactions. The incident you recalled to me makes me think your organization does not have something I hope you and your team members have heard about in an AMRM class: a Just Safety Culture.
Did the flight nurse knowingly NOT raise the door fully? Did he or she do it on purpose? Does management acknowledge that team members are human and will make mistakes? And the question must be asked, was the team properly trained? Did management do the right thing by sending the nurse home without pay because he or she made an honest mistake? I don’t think so, and why not? Because of a lack of a Just Safety Culture recognizing that we make mistakes, and if they are honest mistakes, they should not be punished (because we’re human). We should learn from them and share them with the whole team so the same mistakes are not made in future.
What does it tell the rest of the team if they see one of their team members get punished for making an honest mistake? As you pointed out, perhaps in the future other members will be afraid to speak up the next time something happens, which can have more disastrous consequences than a broken light cover because it sets a terrible precedent.
I cringed when management told you that they treated similar incidents the same way, to send the message that there are consequences for unsafe acts. He is right, but punishing an honest mistake is not
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