How to Murphy-Proof Your Life

By David Carr
Director of Safety














































May 2013



How to Murphy
Proof your Life


The Commandment
L-A-S-E-R

Pilot Safety Award
2013 Incident Stats


Recent Incident
Summaries



I am sure everyone reading this newsletter has heard of
Murphys Law: if anything can go wrong, it will. Being
in the safety business, Ive seen Murphys Law wreak
havoc on a pretty consistent basis so when I think of
Murphy, I cant help but picture this guy:

In the title, I used Life because Murphy-
Proofing is not limited to the workplace.
Sure you dont want Murphy setting up
shop in your aircraft, around your tool-
box or beside you as you deliver patient care. But
just as importantly, you dont want Murphy showing up
on your front doorstep uninvited either.

On page two of our newsletter, one of our most senior
pilots, a man with decades of professional experience
details for us his recent run-in with Murphy. On page
three, another example. This time from a Metro Aviation
pilot who received an unannounced visit from Murphy
while flying at night under night vision goggles.

Our soon to be published Safety Management System
(SMS) manual has a lot to say about Murphy-Proofing
under the section entitled: Risk Management.

Incorporating Risk Management in decision making can
good enough to just come up with risk reducing
solutions, you have to use them.

Step 5: Evaluate. Did your control measures work to
reduce or eliminate the risk? If so, great. If not, then
what else do you need to do to bring the risk to an
acceptable level?

To illustrate the process, lets use Risk Management in a
practical exercise. Suppose that you are the parent of
this young, happy 16 year oldhappy because she just
got her drivers license.





Step 1: Identify the risks your inexperienced child will
face behind the wheel of your new car.

Step 2: Assess those risks. How bad can it be? What is
the likelihood that something bad might happen to her,
to others, or to your new car?

Step 3: Identify control measures. What rules can you
put in place to help her concentrate on driving, and
being safe? I can think of at least a dozen.

Step 4: Implement control measures. You made the
rules, its your car, now you have to enforce them.

Step 5: Evaluate. Are the rules you put in place working
to reduce the chance of something bad happening to
your daughteror your new car?

Thats Risk Management. Of course my kid wouldnt be
driving my new car in the first place (Murphy-Proofing
perfected). The Risk Management process works as well
for a 16 year old driver as it does in flying, maintaining
aircraft or providing medical care, not to mention in your
personal life, finances, relationships etc.

Embrace Risk Management because on that proverbial
dark and stormy night when you really need everything
to line up perfectly, you dont want this guy riding
shotgun.


go a long way to prevent
Murphy from mucking things up.
Here is a Risk Management tool
that is both simple and effective:

Step 1: Identify the risks in your
operation, big and small;

Step 2: Assess the risks. How
severe can they be, and what is
the probability of them having a
negative impact?

Step3: Identify control measures.
Control measures are nothing more
that things you put in place to
reduce or eliminate the risk from
hurting you or crumpling metal.

Step 4: Implement the control
measures. A great plan without
execution is useless. Its not































































MAY 2013
asked if there were any FADEC caution lights and if there
were any exceedances. I told him that everything
appeared normal. He walked me through the FADEC
maintenance check. According to the lights, the FADEC
had not logged any irregularities. He also stated that he
couldn't be sure if anything was logged unless he hooked
up a computer to the ECU. However, with the
information available, he didn't see any reason I should
not complete the flight. I took the patient to the
receiving hospital. Got fuel at the airport and returned to
base. Upon arrival the mechanic met me at the heliport
and hooked the computer to the ECU. He discovered an
exceedance of 117.4% of torque for 0.10 sec. The aircraft
was grounded and I considered resigning. After
consulting with the base manager, the regional area
manager, the chief pilot, the maintenance director, the
quality assurance guru, bell technicians, Rolls Royce
engine experts and God, it was determined that there
was NOT an over torque. In retrospect, it all could have
been avoided if I had just used the checklist, reading
each item and making visual checks.

God gave Moses the Ten Commandments. That is what
they are, Commandments, we violate them at our own
risk. The Chief pilot of Med-Trans also gives out
commandments, one of which is Use Your Check List!

L-A-S-E-R







The Federal Aviation Administration is continuing to see
a dramatic increase in the number of people pointing
lasers at aircraft in flight. In 2005, 283 laser incidents were
reported by pilots. That has exploded to over 2,600 in
2010. "When a pilots eyes are hit by a laser fired from
the ground, or wherever, first of all it impacts his night
vision instantaneously. If it is a very powerful laser it can
literally blind the pilot," said aviation expert Jay Miller.
"Some of these exposures have required pilots to have to
temporarily give up control of an aircraft to their co-pilot
or abort a landing," said former FAA Administrator Randy
Babbitt.

Anyone see a problem with that statement? You got it, at
Med-Trans, we dont have co-pilots to take control of the
aircraft if the PIC is blinded. Flight crews are dealing with
a new generation of green lasers that are extremely


(continued)
.


The Commandment

By Curt Smith
When you were a kid, did you ever go to sit down in a
chair and have someone pull the chair out from under
you? You ended up sitting on the floor with the other
kids laughing at you. When you went to sit down you
expected the chair to be where it had been. It's a
surprise when you end up sitting on the floor. Youre
angry and you want to blame someone for moving the
chair, but to avoid the embarrassment all you had to do
was hold on to the chair as you sat down. There is
nothing difficult about that. So do you blame the kid
that moved your chair or yourself for not noticing the
chair had been moved? Unless you wanted to sit on
the floor and be the joke of the day, you should blame
yourself. The same is true in the aviation industry. Our
Director of Operations empowers each pilot with the
Operational Control of that aircraft. This means that
the pilot is the final clearing authority for the safe
operation of Med-Trans aircraft. We are supposed to
hold on to the chair as we sit down.

The A/C had been in the hanger all night having been
started and run by me, the day before. I had shut the
aircraft down, closed the throttle, turned the boost
pumps off, and made sure everything was turned off
before exiting the aircraft and putting it in the hanger.
The next afternoon I took the helicopter out of the
hanger to respond to an accident scene. During the
start sequence, the throttle was rolled against the stop
to be sure it was in the closed position. Since we were
in a hurry and I expected the throttle to be in the Off
position, I failed to visually confirm that it was in the
Off position. In reality it was in the flight idle position.
I then advanced the throttle until it clicked into the fly
position. Again, I did not visually check the throttle
position assuming it was in flight idle. I initiated the
start sequence while guarding the throttle and the idle
detent. The start was normal until the NG reached 60%
when the engine began an unexpected sudden and
rapid acceleration. I instantly closed the throttle
against the flight idle position thinking it was the cut
off position. As the engine idled at 63% it took a few
seconds for me to realize what had happened. I was
sitting on the floor after having the chair pulled out
from under me. I shut the engine down, turned the
battery off, waited about 30 sec. and turned the battery
on. Everything appeared normal. There were no
FADEC caution lights and no "E's" on any gauges. I
started the engine again. It was a normal start and we
departed the airport to pickup the patient. Upon
arrival, having second thoughts about the initial start, I
called the mechanic and explained what happened. He































































powerful and relatively inexpensive. For about $10, you
can purchase a laser pointer that is strong enough to
temporarily blind a pilot from 1200 feet away. Sounds
like the altitudes we operate at. And even if the laser
doesnt hit the pilot directly in the eye, the glare from
the laser can flashblind him when the beam produces a
blindingly bright glare in the cockpit windscreen.








The box shown below illustrates the hazard to all flight
crews, but especially those who fly helicopters because
of the low altitudes typically flown. Even the weakest
laser pointers (5 mW) when pointed at an aircraft
cockpit at night can be a very serious hazard:












WHAT TO DO IF YOUR AIRCRAFT IS LASED

Dont look at the light!

Maintain or regain control of the aircraft

Interrupt the light by shielding your eyes or
maneuvering the aircraft away from the beam

Turn up cockpit lighting if the glare does not
diminish

Contact ATC and report the incident. If able,
provide landmarks or other means to identify
the location to aid law enforcement response

If your vision is degraded to the point that you
must land immediately, declare an
emergency and request assistance

To report a laser event, go to the sharepoint Safety page,
Click on Incident Reports folder.

For information on the FAAs Laser safety initiative go to:
http://www.faa.gov/aircraft/safety/report/laserinfo/


BH407

1
st
Quarter 2013
Human Error: 2
Environmental: 4
Material Failure: 2
Directed Laser 0

2
nd
Quarter 2013
Human Error: 2
Environmental: 0
Material Failure: 2
Directed Laser 0

EC-135

1
st
Quarter 2013
Human Error: 1
Environmental: 1
Material Failure: 1
Directed Laser 1

2
nd
Quarter 2013
Human Error: 1
Environmental: 3
Material Failure: 1
Directed Laser 0


MAY 2013
Metro Aviation Pilot Recognized for Safety













Left to Right:
Woody Woodard, PIC, First Flight
Mike Stanberry, President Metro Aviation
Metro Aviation recently recognized Joseph Woody
Woodard, Lead pilot for the First Flight program in
Melbourne Florida for his exceptional skill in maintaining
control of an aircraft during an in-flight emergency.

In February 2013, Woodard was Pilot in Command of the
Health First EC135 on a night flight when seven ducks
struck the aircraft. The helicopter was sent into a left
hand dive, and Woodard was left without sight due to
one of the birds hitting him between the eyes, effectively
tearing off his Night Vision Goggles. Ducks broke
through several windows including the windscreen and
one landed in the pilots lap. With a broken nose, cuts
and contusions from flying plexiglass, Woodard was able
to regain control of the aircraft and make a successful
emergency landing at a nearby hospital.

Its hard to train for something like this, but the medical
crew did a good job to keep a calm environment, said
Woodard. Mr. Woodard has been with Metro Aviation
since 1985.

According to the FAA, more than 9,500 bird strikes
are reported each year. Med-Trans crews have
experienced three bird strikes so far within the last 4
months. Keep your head on a swivel and use your
helmet visor--Thats effective Risk Management































































The incident summaries provided here have been collected from around the industry and are shared for general awareness
purposes and in the interest of flight safety.

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
MAY 2013

B-407



During transport into the hangar, saddle of Heliporter
damaged aft crosstube requiring replacement of tube.
Human Error cost: $3,500 (est).



After mission completion, the NG Gauge brightness
would not respond to instrument lighting rheostat. All
other gauge lights were operating normally. After
attempting to troubleshoot with the rheostat, the pilot
tapped the edge of the NG gauge and the IR filter
cracked. (note: this sounds pretty harmless, but IR
filters are expensive. Estimated cost to replace: $800+)

Ec-135

While in cruise flight at 4500MSL, bird struck right side
of co-pilots windscreen. No damage done, except that
there is one less bird to hit in the future.


Crew and patient were offloaded at hospital. The
through flight inspection was completed and the cabin
area was checked for security of equipment. Pilot
completed a walk around and departed the hospital pad
for fuel. While enroute, a cabin door came open at at
50-60 knots. After landing the pilot inspected the door,
cabin area and the reminder of the aircraft. No damage
was noted and no equipment or gear was missing. Pilot
acknowledged that he failed to assure the cabin door
handle was firmly into the closed position prior to lift
off.
Director of Safety
David Carr
David.carr@med-trans.net
The Med-Trans Leadership Team
Chief Operating Officer
Rob Hamilton
Hamiltonrobert@med-trans.net

Director of Operations
Bert Levesque
levesquebert@med-trans.net

VP, Program Operations
Connie Eastlee
Eastleeconnie@med-trans.net
Director of Maintenance
Josh Brannon
Brannonjoshua@med-trans.net

Chief Pilot
Don Savage
Savagedonald@med-trans.net

Assistant Chief Pilot
Mike LaMee
Lameemichael@med-trans.net

VP, Flight Operations
Brian Foster
Fosterbrian@med-trans.net


AND FINALLY,
With spring upon us, you might be itching to get outside
and start trimming. May I suggest you benefit from the
experience (or mishaps) of others...