How We Will Learn, How We Will Change
Following is a four part series that was posted over a period of several months. It looks a headlines and asks how we as an injustry may learn and improve our practices to create a safer culture for all.
Part I
In what has been described as one of the worst airline crashes in recent years a small commuter airplane crashed into a suburb outside Buffalo, NY. Initially it was believed that ice build up on the wings likely caused the crash.
At 10,000 feet, and under, after take off and approach to landing, pilots are required to maintain 'sterile' communication, talking only about the plane and the flight. In this crash both pilots violated this policy. In fact they both spoke of their inexperience.
Training is required for pilots regarding icing, stalls and other potentially hazardous conditions. Colgan Air, who operated this flight for Continental, by their own admission, did not provide this training.
The co-pilot is heard to state she has never flown with ice- has never been through deicing. The pilot was classified as a slow learner who improved. The plane stalled because the minimally experienced pilot reacted incorrectly when the plane gave a pre-stall warning.
Had the airline performed the required training, this crash, which killed 50 people, need never have happened.
Had the pilots had the necessary and required experience, this crash need never have happened.
Had the pilots followed the 'sterile' policy and focused on the flight during this critical time, this crash need never have happened.
In EMS we need to learn from all examples that offer insight into preventing catastrophe. This is a perfenct example. We also need to employ the same surgically precise investigation following our own events to determine the true cause- in order to prevent recurrence- in order to save lives and careers.
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Part II
I recently posted a story about how we should learn from the Continental Airline crash earlier this year that killed 50 in upstate NY. This time I want to focus on an ongoing event that took place in Kentucky.
It began over a year ago in Louisville with a crash that killed the 54 year old patient. A witness who had been following the ambulance said that the ambulance had been weaving all over the road. The medic in back was so concerned about the ride that he texted his supervisor with his concern and the supervisor had decided to take the driver off the road after this call. Additionally the patient's family said the driver repeatedly apologized for being sick and stated she had taken cold medicine.
Prior to being hired her driver's license check revealed that she had a previous reckless citation for going 23mph over the posted speed in a school zone.
Now she has been picked up for being in a collision in her own car and not having insurance. Both criminal and civil actions are pending.
So what lessons can and should we learn from this?
If you told your supervisor that you were too sick to safely drive or had taken too much cold medicine, what would the response be? If you are a supervisor and were told this how would you respond? Does the culture exist that makes this honesty accepted rather than frowned on?
Is the culture such that one employee can 'report' another without repercussion?
Can we teach to simply tell the driver to pull over.
Do we interact enough with employees to be able to recognize warning signs?
Based on the information presented- this death was completely preventable. How will you prevent a similar occurrence in your area?
Imagine you are the company defense attorney- what will you say to make these events seem ok? What is your defense strategy?
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Part III
May 2007, Waterbury, CT two fire trucks collided responding to a fire. They both failed to account for the other vehicle. One firefighter died and another suffered a brain injury.
Today May 22, 2009, Connecticut State police released their findings on a collision that occured in September involving two New Haven Police Cars that collided in an intersection. Both were responding to the same call. Both failed to account for the other. One officer died, the other has suffered a brain injury. The call for a woman being assaulted ended up being a false alarm. The report went on to state that speed was a factor and that neither car slowed down. The report found fault with the officers.
In an interview, Police Chief James Lewis stated that this should not take away from what they did in the past and what they were trying to do that night. On the surface it is obvious they were trying to help the woman being assaulted. In addition they were endangering the life and health of every other person on the road that night. Did they have that right. Do emergency vehicles today have the right, by careless actions, to risk the lives of others?
Chief Lewis also stated that, "We hammer it home, talk about, train; we have policies. The reality is this will happen again in some manner." In times like this we certainly don't want to blame or to punish the deceased. We also don't want to look inward as the responsibility for such events rarely rests with one person. The Chief is admitting that he has no control over his officers and it is clear that there is no accountability for policy infractions or rule violations. As a reult the Chief, unfortunatley is right, officers will continue to die and people like Chief Lewis, afraid to admit fault, call it a shame.
This outcome is both predictable and completely preventable. This collision, this death need never have happened. Chief Lewis should step down as should anyone in a similar role who believe such events must continue.
EMS, Fire or Police- we share many of the same risks, we sometimes share the same outcome. In both these collisions the dead still are and the police officer with the head injury is still hospitalized. Ours is not to risk lives, ours or others, even for the sake of others.
We need to learn- we need not die like this. If you agree, please forward this message and warning on.
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Part IV
Following the mid-ocean crash of Air France's flight 447, investigators began the arduous task of determining why and how. One early indicator was that there may have been a problem with an airspeed sensor. Flight 447's plane was an Airbus A330. In March of 2006, Airbus issued a safety advisory suggesting the possibility of failure of these sensors and that airlines begin a schedule of replacement.
Following the crash, the pilots union for Air France cautioned pilots not to accept any Airbus where this replacement had not been done. Following the crash Air France and other Airlines began replacing these sensors.
Following a crash that claimed 228 souls is not the time to heed a safety advisory. Like many collisions and injuries that occur in EMS this event was predictable and the outcome preventable.
