In the first blog on this site, I posed the notion that those in helicopter medevac had daily experience and knowledge in this arena that could be collectively accessed to prevent accidents that are costing people’s lives. The proliferation of accidents is alarming and there needs to change. I asked if those in the industry could talk about this. Clearly, no one stepped up to the plate most likely because of fear of reprisal, or fear of looking bad.
Today, I am going to make a different suggestion based on something I have discovered — Kaizen. I discovered this in a program by Nightingale Connant. This is a system that evolved out of Asian philosophy which seeks to look for small steps to make improvements that will ultimately make great improvements or avoid terrible disasters. Several examples are sited in industry. Firestone ignored the seemingly small problem with their tires until they resulted in multiple accidents costing many lives that resulted in lawsuits and bad press. The Columbia space disaster that killed seven astronauts resulted because NASA tended to ignore small amounts of foam ripping away the craft’s structure until a massive amount ripped away on re-entry resulting in disaster.
We can all think of incidents in our own life where there were small signals of the possibility of an evolving problem, but we turned a blind eye or ear only to discover a greater costly problem later. It certainly is advisable to reflect on this notion which might be reflected in personal relationships that went sour or business decisions that were not sound. The idea of asking small questions to make small improvements that ultimately can result improved performance and cost savings, or catastrophe has been proven by research. We tend to think it is only big changes that will result in big results.
Organizations demanding high reliability must find ways not to fail. Helicopter medevac and hospitals are certainly qualify as high stakes environments. Survival of institutions and people make it so. A culture of openness where employees are encouraged to discuss small or large problems without fear of reprisal needs to be encouraged. Some institutions have even found ways to reward employees for bringing attention to problems. Group think is a phenomenon that has been researched and been proven to exist and contribute to costly mistakes. I don’t expect people or organizations to display their dirty laundry in a public forum. However, I do believe there are things that exist that people and institutions are turning a blind eye or deaf ear to. Here are some things that one might consider. The key to success will be to create a culture of openness and a willingness to take action.
- Deficient administrative knowledge that may negatively impact how a program operates.
- Problems of performance of equipment such as the rotor blades sited in an earlier post that resulted in an accident killing the pilot.
- High level of competition and how this might affect performance.
- Long hours on the job with nothing to do, but wait for a call.
- Pressures on pilots to fly.
- Standards of conduct or performance.
- Action or inaction by FAA
- NTSB findings after an accident: what might have been noticed, and discussed to determine if there were small things that ultimately led to an accident.
- The use of night goggles and terrain sensing equipment has been left to self-policing and voluntary compliance. Developing standards and evaluating compliance by an organization charged with this responsibility is slow to non-existent.