Publication

OCT-DEC. 2014
SafetyMatters
America’s Medical Transportation Safety Newsletter
A quarterly, collaborative publication
from MedFlight and HealthNet
Aeromedical Services
Association of
Air Medical Services
Welcome AAMS Members!
SafetyMatters is published collaboratively on a
quarterly basis by MedFlight, based in Columbus,
Ohio, and HealthNet Aeromedical Services, based in
Charleston, West Virginia.
These not-for-profit programs operate the nation’s
only jointly sponsored air medical helicopter base
and have fully integrated the safety programs of their
respective systems.
SafetyMatters is just one example of the MedFlight/
HealthNet Aeromedical Services partnership.
THIS ISSUE INCLUDES:
• Managing Hazards in the Workplace Using Threat and
Error Management Skills
• Safe Sled Carriage
Managing Hazards
in the Workplace Using
Threat and Error Management Skills
By Colin Henry
Vice President of Safety
MedFlight
Threat and Error Management (TEM) is:
• An overarching safety concept regarding
operations and human performance.
• It is the practical application of human factors
strategies in the management of threats and
errors.
• It is an active process to identify threats and
develop strategies to avoid or mitigate them.
A threat and a hazard could be used in a similar
context and has the ability to exist in any area of
your work environment. For example, it can occur
during a ground transport, in flight, in the operating
room, in the emergency room, etc. Threats/
Hazards are risks from events or situations that can
lead to an error. They are a precursor to an error
and are usually present before the error occurs.
Since they occur outside the influence of humans,
they may increase operational complexity and will
require attention and management if safety margins
are going to be maintained. Some examples of a
threat/hazard include weather, terrain, a complex
medical procedure, or an equipment malfunction.
TEM accepts that human error will occur. This
human error is defined as actions or inactions that:
• Lead to a deviation from humans or
organizational intentions or expectations.
• Reduce safety margins.
• Increase the probability of adverse operational
events in all areas of our operation.
According to Dr. Helmreich, “The easiest way
to understand Threat and Error Management is
to liken it to defensive driving for motorists. The
purpose of defensive driving is not to teach people
how to drive a vehicle (e.g., how to shift a manual
Continued next page >
• Considerations for Selecting
and Using Helmets
• Backing Safety
As Dr. Don Arendt explains: “ Hazards and threats don’t come to us with part num
identifying them as threats. They often don’t have inherent characteristics that ide
Managing Hazards in the Workplace Using
Threat and Error Management Skills Continued
them as obvious, (conditions that could cause an accident). Every operation is affe
by the system in use and the operational environment that it is conducted. These
transmission) but to emphasize driving techniques that people can use to
As Dr. Don Arendt explains, “Hazards and threats don’t come to us with
conditions
up the situation
sets
stage
foroften
performance.
minimize safety risks (e.g., techniques to control rear-wheel skids).”
So we make
part numbers,
identifyingthat
them
as the
threats.
They
don’t have Performanc
inherent
a number
of outcomes,
themassuccessful
but sometimes
ending
must develop Human Factor Strategies and Countermeasures tohave
manage
characteristics
that most
identifyofthem
obvious (conditions
that could
causethe
threats and errors in the workplace.
an
accident).
Every
operation
is
affected
by
the
system
in
use
and
the
operation in failure.”
Internal Threats Latent Threats
Active Threats External Threats
Threats
Human Factors Strategies
and Countermeasurements
Management
Errors
operational environment that it is conducted. These conditions make up
the situation that sets the stage for performance. Performance can have a
number of outcomes, most of them successful but sometimes ending the
operation in failure.”
Skilled Based Slips/Lapses Rule Based Mistakes
Knowledge Based Mistakes
So we have identified four types of threats:
So we have identified four types of threats:
• Internal – These are internal to your organization or are personal. Some examples
The potential for errors or failures in the operations may occur when there
are–fatigue,
of staff, to
autocratic
leadership and poor
safety
culture. Some
• Internal
Theseshortage
are internal
your organization
or are
personal.
are system and/or environmental threats/hazards. These threats/hazards may
• Latent
are threats/hazards
are autocratic
not apparent and
that are inherent
in
examples
are– These
fatigue,
shortage of that
staff,
leadership
and poor
be a single factor or a combination of factors that may become hazardous
the system. For example, people know about it but may not recognize it as a
safety culture.
when
they interact.
For example,
complex maintenance
on are
our sys
The
potential
for errors
or failures
in the operations
may occurprocedures
when there
threat until it leads to an error. They are often missed or ignored when they lead
aircraft or our
ambulances, andThese
long threats/hazards
work schedules could
to fa
to a consequential error. For example, personnel have gotten into the practice
of environmental
and/or
threats/hazards.
maycombine
be a single
• Latent not
– These
threats/hazards
thatsupervisors
are not don’t
apparent
and that are
hazardous levels.
observingare
some
of the procedures and
intervene.
combination
of factors
become
hazardous
when
they when
interact.
For exam
inherent
in the
system.
For example,
people know
it butamay
Some
failuresthat
maymay
be active
or latent
and may be
escalated
defenses
• Active
– These
threats/hazards
usually materializes
duringabout
actual operations
andnot
are
typically
recognizable.
For
example,
hazardous
weather
or
an
incompetent
complex
maintenance
procedures
on
our
aircraft
or
on
our
ambulances,
and
recognize it as a threat until it leads to an error. They are often missed or
are broken down due to management decisions, organizational processeslong
ignoredcrewmember.
when they lead to a consequential error. For example, personnel
and error/violation
conditions.
schedules
could
combine toproducing
hazardous
levels. The outcome is an accident.
External
– These
are external
yourobserving
organizationsome
which the
organization
does
have•gotten
into
the practice
oftonot
of the
procedures
and
not have control over. Some examples are crowded airspace, slippery roads or a
supervisors
don’t
intervene.
combative
patient.
Some failures may be active or latent and may be escalated when defenses are br
As you may note, sometimes a single threat may fit the definition of
down due to management
• Active
– These
types. threats/hazards usually materialize during actual operations
multiple
producing
and are typically recognizable. For example, hazardous weather
or an conditions. The
We have also identified
three types of errors:
incompetent
crewmember.
decisions, organizational processes and error/violation
outcome is an accident.
• Skilled Based Slips/Lapses – These result from a failure to execute an action
• External
– These
are of
external
your
organization
and
the to
organization
correctly
regardless
whether to
or not
the plan
was adequate
enough
achieve
does not
have control
over.a skill
Some
examples
aretocrowded
airspace,
its objectives.
This is usually
that we
have but failed
execute it correctly
slipperybecause
roads we
or missed
a combative
a step or patient.
forgot to do something and now an incident or
accident has occurred.
As you may note, sometimes a single threat may fit the definition of multiple
types.
We have also identified three types of errors:
• Skill Based Slips/Lapses – These result from a failure to execute an
action correctly regardless of whether or not the plan was adequate
enough to achieve its objectives. This is usually a skill that we have
but
failed to execute it correctly because we missed a step or forgot to do
The last lineThe
of defense
threats, errors
that undesired
operational
state is stil
something and now an incident or accident has occurred.
last lineagain
of defense
againstand
threats,
errors and
that undesired
ultimatelyoperational
the human.
That
undesired
operational
state
is
a
position,
condition,
or
state is still ultimately the human. That undesired operational state
attitude that
clearly
reduce or
safety
margins
andclearly
is a result
of actions
from usand
• Rule Based and Knowledge Based Mistakes – This is when a decision
is a can
position,
condition,
attitude
that can
reduce
safety margins
was made that was a deficiency or failure in judgment. Rule based
a aresult
of compromising
actions from humans.
is a safety
state that
humans. is
It is
safety
state thatIt results
fromcompromising
ineffective error
mistakes account for not following a procedure or process that is in place.
resultsThese
from ineffective
error management.
management.
three concepts
should be adopted:
•
•
Anticipation: Staying alert, knowing that you can’t possibly predict everything tha
Continued
next page >
can go wrong. Maintaining a state of vigilance and avoiding
complacency.
Recognition: The sooner you recognize that something is not right, the faster you
can act to mitigate that threat or error. Early recognition obviously aids recovery.
Considerations for
Selecting and Using
Helmets
Managing Hazards in the Workplace Using
Threat and Error Management Skills Continued
These three concepts should be adopted:
• Anticipation – Staying alert, knowing that you can’t possibly predict
everything that can go wrong. Maintaining a state of vigilance and avoiding
complacency.
Dudley Crosson, PhD
Delta P, Inc.
• Recognition – The sooner you recognize that something is not right,
the faster you can act to mitigate that threat or error. Early recognition
obviously aids recovery.
Introduction
• Recovery – This is you intervening in what will soon become, or has
already become, an undesired operational state. n
Wearing the proper flight gear during flight is critical for the safety of the
crewmembers. While it can be argued that the absolute necessity of wearing
a helmet, flight suit, proper boots and gloves all of the time is unnecessary,
it is for that one time (that hopefully never happens to anyone) when the
aircraft unexpectedly goes down. That is when all of this equipment’s value
may come into play. Essentially it is insurance, as are your automobile seat
belts. Crash investigators often hear from crash survivors that they are able to
speak to us singularly because they were wearing their Aviation Life Support
Equipment (ALSE). The FAA does not mandate use, but for survivability in
numerous cases, this is not an option, it is an imperative and should be
considered an industry standard.
This paper focuses on helmets. The helmet is considered by some to be
the most important ALSE to be worn. In many ways this is true, but there are
a few more considerations than just to wear one, which we will discuss later
in the paper.
References:
Arendt, D. Toward a Common Understanding of Risk
Reason, J. Human Error
Air Facts Journal. Threat and Error Management: a primer
Safe Sled Carriage
By Colin Henry
Vice President of Safety
MedFlight
A great majority of the flight programs in the State of Ohio use a sled
type patient stretcher which requires transport via “hospital gurney” from the
aircraft to bedside. The mechanical part of the gurney that raises and lowers
the head frame takes a “beating,” particularly at busier facilities. The worn
head frames can cause hang-­ups or snags that have contributed to employee
injuries. In addition there is the potential for a patient safety event to occur
such as an accidental slip off the gurney or sled.
Riverside Hospital and The Ohio State University Medical Center (OSUMC)
have been working with MedFlight to address this problem. The Riverside
solution is inexpensive and simple. The picture below is of a 1” piece of marine
grade plywood with Formica-like material laminated to the surface. The side
rails and IV poles are free to move. The plywood is secured to the gurney with
1” strips of Velcro® which are very strong. The gurney maintains its original
functionality if needed. Reports from MedFlight crews are all positive. Dixie
Davenport,
the EMS Coordinator at Riverside Hospital, collected feedback
A great majority of the flight programs in the State of Ohio use a sled type patient stretcher which requires transport via “hospital gurney” from the aircraft to bedside. The mechanical part of the gurney that raises and lower the head frame takes a “beating,” particularly t busier facilities. Twere
he worn head frames can surveys
from
programs
landing
Riverside;
all asurveys
positive.
A great majority oall
f the flight
flight programs in the State of Ohio use a sled type at
patient stretcher which requires transport via “hospital gurney” from the aircraft to cause hang-­‐ups or snags that have contributed to employee injuries. In addition there is the potential for a patient safety event to occur such as an accidental bedside. The mechanical part of the gurney that raises and lower the head frame takes a “beating,” particularly at busier facilities. The worn head frames can slip off tare
he gurney or scourse
led. There
of
some
suggested
enhancements
that
are
cause hang-­‐ups or snags that have contributed to employee injuries. In addition there is the potential for a patient safety epresently
vent to occur such abeing
s an accidental slip off the gurney or sled. Riverside Hospital and OSUMC has been working with us to address this problem. The Riverside solution is inexpensive and simple. This is a picture of a 1” piece assessed.
of marine grade plywood with Formica like material laminated to the surface. The side rails and IV poles are free to move. The plywood is secured to the gurney Riverside Hospital and OSUMC has been working with us to address this problem. The Riverside solution is inexpensive and simple. This is a picture of a 1” piece with of Velcro which improve
are very strong. The gurney msystem
aintains its original functionality if needed. Reports from our crews are all positive. Dixie Davenport, We1of ” smtrips hope
this
and
each
Columbus,
Ohio
arine grade pto
lywood with Formica like m
aterial laminated to the surface. The have
side rails and IV poles are free to move. The plywood is secured area
to the gurney the EMS Coordinator at Riverside Hospital collected feedback surveys from all programs landing at Riverside; all surveys were positive. There are of course some with 1” strips of Velcro which are very strong. The gurney maintains its original functionality if needed. Reports from our crews are all positive. Dixie Davenport, suggested enhancements we currently looking at. hospital
maintenance
department
develop
one
for
system.
the EMS Coordinator at Riverside Hospital collected feedback surveys from all programs landing at Rtheir
iverside; ahospital
ll surveys were positive. There are of We
course some suggested enhancements we currently looking at. We hope to improve this system and have each Columbus Area Hospital Maintenance Department develop one for their hospital system. We would also like to also like to work with hospitals statewide to follow suit. The goal is
would
convince hospitals statewide to follow suit. The goal is to minimize the risk of injury to employees and patients while keeping this innovation simple. We hope to improve this system and have each Columbus Area Hospital Maintenance Department develop one for their hospital system. We would also like to convince hospitals statewide to follow The goal ito
s to minimize the risk of injury to employees and patients while keeping this innovation simple. to minimize
the
risk
of suit. injury
employees
and
patients
while
keeping
this
innovation simple. n
Why Use Helmets?
Surprisingly, there are still helicopter companies/units that do not
require helmets or they employ crewmembers that do not want to use
them. Fortunately this is not the norm and hopefully in time professionalism
will mature their perspectives. One needs to consider proper fit and
characteristics for both short-term health such as survivability and shock
absorption, and long-term health for hearing loss mitigation, and neck and
back myalgia mitigation. Two of the three aspects, short-term health and
hearing loss mitigation, are provided by the helmet.
Commonly the only characteristics of a helmet that are examined are the
short-term health aspects of the helmet. This is certainly the most impressive
aspect, and is supported in a study by Taneja and Wiegmann (2003). They
“analyzed patterns of injuries sustained by pilots involved in fatal helicopter
accidents from 1993 to 1999 by reviewing the FAA’s autopsy database.”
This database included all helicopter accidents, including HEMS, tourism
and public safety. A couple of very impressive details to come from this; 1.
skull fractures were the second most common result experienced from blunt
force trauma at 51% of the cases, and 2. the brain was the most common
significant (62%) of the organ/visceral traumas. By examining the patterns, it
is safe to say that those not wearing helmets experienced the most significant
head trauma.
Choosing a Helmet
Selection
A common question is which one is the best? I do not believe there is a
"best," but there are several options based on your specific needs. There are
Continued next page >
Considerations for Selecting and Using Helmets Continued
a number of acceptable helmets to select from, the key being a reputable
product based on articulated supporting test data to see how the helmet
performs when compared to others. Certainly the HGU-56/P (current U.S.
Army helmet) goes through the most rigorous testing. It is built to provide
adequate protection in the context of an otherwise survivable crash scenario.
Understand that the Army fleet contains much larger rotary wing aircraft than
our civilian fleet, and the crash kinematics and dynamics can be much more
severe. These airframes are ruggedized for combat and contain crashworthy
seating that provide survivability from the vertical components of the crash, but
the resulting flail experienced by the crewmember is much greater than noncrash worthy seating and the probability of head trauma is understandably
much greater. The main complaint of this helmet is that it is seen as large
and bulky. While it meets the protection requirements for the military, that
does not necessarily mean it is the best for your needs. Remember, the
helmet is also the base platform for your eye protection, hearing protection,
communications and night vision augmentation.
Night Vision Goggles (NVGs) have evolved into a prominent part of
our night operations. So when selecting a helmet, ask the vendor about
the helmet’s Center of Gravity (CG), and where that helmet falls within the
longitudinal and lateral risk curves established by the U.S. Army Aeromedical
Research Laboratory (USAARL), to set recommended limits for significant
neck trauma in a crash. These curves are commonly known in the industry as
the USAARL curves. The CG will dictate if/how much counter balance weight
will be needed. This is important because the more weight added to the head,
the higher the potential for neck/back problems in the future. The closer to
the body’s midline axis the CG is, the better. Some helmets with a centered
CG and a snug nape strap may not require any counter balance weigh at all.
The proper CG coupled with appropriate exercises and stretches will go a
long way to mitigating any future chronic neck and back problems. Excessive
weight may negatively affect the cervical neck leading to disabling neck
trauma and, therefore, should have a break-away feature.The vast majority of
the NVGs on the market have such a capability. Continue to include a break
away consideration for that weight bag, camera, or other sighting devices as
well.
This brings us to another characteristic of the helmet, that being the nape
strap. It is imperative that the helmet has a device that can be secured below
the occipital lobe (the bump on the back of your head). This prevents the
helmet from sliding/rotating forward and possibly coming off in a crash.
Standards
While it is true there is no single helicopter standard that needs to be met,
there are aspects that helicopter helmets address that fixed-wing helmets
do not; this will be discussed further in the paper. The important thing to
remember is ensure that the helmet you select meets a helicopter standard
and not a fixed-wing standard.
Once you have narrowed your search down to a couple of helmets,
three VERY important steps are: 1. ensure that the vendor is recognized by
the manufacturer, 2. ensure the vendor can accurately explain the data on
the safety features of their product, and 3. examine the specifications. It is
imperative to find out what the design specifications are, what test standards
were used and where was the testing done. Did the helmet protect the head
from the injurious G-forces? What noise levels did the ears receive and across
what frequencies? What testing was performed by the visor and what is
it made of? It is important to make sure they provide you with the design
specifications and not generic ANSI standards. ANSI standards, such as the
ANSI Z90.1 are testing guidelines; these ensure all testing is standardized.
They are not test result requirements, they are test procedures. We will provide
a sheet of standards used for U.S. Army flight helmets in a future paper.
The design specifications will inform you as to what the particular helmet
will allow in terms of G-forces to the head at specific velocities of impact. If
a recommended standard for an automobile bumper is to protect the vehicle
from any damage up to a five mile an hour impact against a solid wall, why
would you accept a standard that would protect you from only a two mile
an hour impact? Would you really trust the vendor who is telling you “See?
It passed our test." This is the most important issue for initial/immediate
survivability. It is not only critical to survive the accident, but to maintain the
ability to egress the aircraft. This is defined as maintaining the head below the
level of non-concussive injury and is commonly called Conscious Survivability.
In Vietnam, the Army learned that they needed to make their design
specifications more stringent because a number of accidents occurred that
were otherwise survivable, only to have the occupants perish in the post-crash
fire. These specifications will address performance pertaining to protection
issues such as mechanical insult from structure and impact (the shell), hearing
protection and impact attenuation (ear cups), impact attenuation (liner),
helmet stability, ear cup placement and security (harness), and a comfortable
fit (inner liner or suspension assembly). As mentioned above, you need to
ensure this is a helmet specifically designed for helicopter use. A fixed-wing
helmet does not require anywhere near the protection levels of a helicopter
helmet. Helicopter helmets are meant for multiple tangential strikes due to the
fact that once on the ground the blades continue to rotate, commonly striking
objects that cause significant vibration in the aircraft. This energy translates
into multiiple strikes to the head. This is one of the reasons helicopter helmets
are heavier than fixed-wing.
The design specifications do not only focus on short-term survivability.
They should also lay out the requirements for hearing protection and visor/
eye protection. Hearing protection comes primarily from the ear cups, and
communications are a function of both the speakers in the ears and the
microphone used. Enhancements may include inner ear speakers, a helmet
edge roll-pad, etc.
Once you have decided that the offered product meets your needs, the
next step is to assess the testing data provided to ensure that the helmet
meets the desired design specifications as mentioned earlier. Since we
mentioned the HGU-56/P, some examples of standards it has are:
Shock Absorption
MIL-DTL-87174A
Perforation Protection
MIL-H-87174
Retention System
EN966
Visor
MIL-V-43511B
I cannot stress enough that when choosing a helmet, always require
the manufacturer to provide you with the final test report from a third party
neutral ISO certified laboratory or recognized U.S. Government testing
facility that proves successful completion verifying the helmet truly meets the
design specifications stated. Without this data, you cannot be certain of the
performance of the product. Verbal claims and/or brochures are of no value
in this arena.
After the Purchase
Once the helmet of choice is purchased, it needs to be properly fit.
Meaning, it is important to follow the manufacturer’s recommendations.
In one case, a mold of the top of the head may be made and sent to the
Continued next page >
Considerations for Selecting and Using Helmets Continued
manufacturer prior to delivery of the helmet so that they may do the initial
fit/sizing for a specific user. After that, fine-tuning may be done in order to
eliminate any "hot spots" to optimise the fit and security. The reason this
is emphasized is that without a good fit, the helmet will be uncomfortable
and at the very least the wearer will suffer through the flight, distracting them
or diminishing their performance during the mission, or the helmet may not
be worn at all. After wearing the properly fit helmet for a couple of months
(especially through hot months), check the fit again. Straps tend to stretch
and internal padding tends to form. A simple test is to reach back and grasp
the base of the helmet and pull forward across the top of the head and then
from side to side. Do this yourself. Another person cannot adequately assess
your neck limits and unintended strains could occur. If the helmet slides off
the head, it is too loose. Related to this is the common mistake of users not
properly securing the nape strap. When all is done, with a secure neck and
nape strap, the helmet should be comfortable enough to be worn for several
hours at a time.
Once the helmet is fit properly and in use, it is critical to remember to wear
your visor down if possible, either the tinted or the clear one. In addition to
protection in crash scenarios, the most common visor impacts are caused by
bird strikes, but other times it is important as well such as when a crewmember
is on the skids during hoisting operations. There are no sunglasses that
protect against that much impact with the same area of coverage. If you are
purchasing a helmet with two visors, ask the manufacturer to place the clear
visor on the inside. The reason for this is individuals may find the clear visor
can be down and still be able to wear future NVGs at night.
Now that short-term health has been addressed, we need to consider
long-term. It is very rare that users consider this when choosing a helmet.
The two most common chronic issues are hearing loss and neck/back pain
and/or neurological damage. Let us look at noise first. The helicopter crew
is exposed to a wide range of frequencies and intensities such as engine(s),
drive shafts, transmissions, rotors and propellers. The Surgeon General has
established 85 dBs as the generic maximum level of continuous, unprotected
exposure to steady-state noise for eight hours. Obviously no helicopter
operates at or below 85 dBs, so hearing protection is needed, which is
mostly provided by the helmet system. Proper fit also helps here because
of the fit of the ear cups and insulation of the helmet. Hearing protection is
an area where helmets vary greatly. There is a way to help protect against
the noise level and that is by also wearing earplugs. Certainly if funding is
available, Communication Ear Plugs (CEPs) are an option. It is essentially a
foam earplug with a hole drilled through it length-wise and a speaker inserted.
While the communications are clear and often times the volume can be turned
down, some crewmembers feel the CEP is putting pressure inside the ear.
As many cases, this is personal preference. Finally, some individuals feel
the ultimate protection is Active Noise Reduction (ANR). This is built into the
helmet and works by 180-degree out-of-phase signal at the same frequency
and amplitude to cancel the target ambient noise. Theoretically it cancels any
undesirable noise by superimposing an inverse sound wave. At the recent
Aerospace Medical Association annual meeting, it was presented that ANRs
do not mitigate hearing loss like originally thought. So, at this time, there is no
scientific evidence that supports this claim.
Another long-term health issue is that of neck and/or back pain. Just by
virtue of having to wear a helmet weighing between two and four pounds for a
long period of time, this should be expected. Combined with this is the head
movement associated with flying a helicopter, often times looking down and
to the side. Lastly, for those using NVGs, these add weight plus additional
"add-ons" such as batteries and the counterweight. We commonly see
individuals who have been flying for several years to have neck and/or back
pain, sometimes only when flying and others all the time. Neck exercises are
certainly warranted in order to avoid such pain. Another is to utilize something
commonly used by NASCAR drivers to support their helmets, a nomex neck
support. It is similar to the pillows used by travelers on planes that wrap
around the neck. In this case, it is firmer and supports the weight of the
helmet without limiting the turning of the head.
Summary
Helmets are a critical component of the crewmembers’ ALSE. When
thoroughly researched, intelligently selected, and properly fit, this goes a long
way to making the helmet much more tolerable to wear. To put this in a “nut
shell," ensure:
• You asked for, and have been provided, a copy of the helmet specifications
used in testing.
• You asked for, and have been provided, a copy of the complete test
report.
• You have sufficient information to provide your personnel a proper fit.
• You always wear your visor in the down position.
• You do everything possible to protect your hearing including ear plugs.
• You are aware of potential musculoskeletal/neurological issues.
• You have your helmet inspected annually by a trained ALSE professional.
Acknowlegement
I would like to thank the U.S. Army Aeromedical Research Lab for its
support in writing this paper. n
References:
Alem N., Mobasher A., Brozoski F. & Beale D. Jan 98. Simulations of head strikes in
helicopters and the roles of restraints, seat stroke, and airbags on their reduction.
U.S. Army Report USAARL No. 98-11:
Ang B. & Harms-Ringdahl K. July 06. Neck muscle and related disability in helicopter
pilots: a survey of prevalence and risk factors. Aviation, Space and Environmental
Medicine 77, No. 7: 713-719.
Brozoski F. & al e. Feb 08. Impact protection assessment of the redesigned Oregon
Aero ZetaLiner fitting system in the HGU-56/P aircrew integrated helmet system.
U.S. Army Report USAARL Report No. 2008-07:
Brozoski F. & Licina J. Nov 05. Static and dynamic retention assessment of the HGU56/P aircrew integrated helmet system equipped with quick-release ALPHA and
snap fastener retention assemblies. U.S. Army Report USAARL #2006-02:
Butler B. & Alem N. Aug 97. Long-duration exposure criteria for head-supported mass.
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USAARL Report No. 2012-14:
BACKING
SAFETY
Articles by Billy E. Rutherford
President of American Integrated Training Systems, Inc. (AITS)
The Importance of Hand Signal
Standardization and High Visibility Gears
During the reviewing of several Standard Operating Procedures (SOPs),
AITS learned that many organization SOPs are incomplete or vague about
backing procedures, hand signals and the use of a spotter, and there were
organizations that did not require a spotter when backing. During literature
search, AITS also reviewed the hand signals for spotters to use and found a
variety of word descriptions and illustrations for hand signals. Many SOPs did
not discuss the hand signals. During visits to organizations, AITS discussed
the importance of having standardized hand signals for backing. It's often
that even if the SOP provided a description and photo of the hand signals
to use, the organization's personnel did not always use them, or use them
correctly. It was interesting that even at the same station, the hand signals
varied between individuals and crews.
About the Author
Dudley Crosson is an Aeromedical Safety Officer (AmSO) and the Principal
of Delta P, Inc. The focus of Delta P is to increase the operational efficiency
and safety of the aircrew and others participating in air operations in order
to ensure "mission completion" by providing aeromedical consultation and
identifying and countering aeromedical threats facing today's crew members.
Dr. Crosson’s PhD is in physiology and has successfully completed the
ERAU’s Aviation Safety Management program and the U.S. Navy’s Aviation
Safety Officer school. He is a member of the CAMTS Aviation Safety Advisory
Board and the Aerospace Medical Association’s (AsMA) Aviation Safety
Committee. Along with Delta P he is the Aeromedical Liaison for the Airborne
Law Enforcement Association and an Affiliate Professor at the University of
Hawaii-Hilo.
Dr. Crosson can be reached at:
772.359.3680 | [email protected]://delta-p.com
AITS also reviewed the universal procedure that defines the action to take
when the vehicle operator loses sight of the spotter. It is interesting to note that
AITS has asked what the vehicle operator should do when they lose sight of
the spotter. Hundreds of times during Emergency Vehicle Operators Course
(EVOC) training people always hear the same answer – STOP! Yet each year
spotters are killed when the vehicle operator backs over them because the
operator did not stop when they lost sight of the spotter. It is a procedure that
everyone knows – but often does not follow, and it has fatal consequences.
AITS visited organizations that had Rear View Cameras (RVCs) on their
vehicles. The AITS team was eqipped with both video and still cameras, with
a simple objective – observe the backing procedures with and without the use
Continued next page >
Backing Safety Continued
of the RVC. The organization's SOP had a backing procedure and described
the hand signals to be used by the spotter. Unfortunately, the vehicle RVCs
were not operational. A quick check revealed that the camera simply needed
to be adjusted and to the crew's surprise the cameras became operational.
The AITS team then observed as four different spotters at the same location
used different hand signals to back a vehicle into a bay. The greatest concern
was the disappearance of the spotter as he moved into the dark vehicle bay.
The spotter and the hand signals could not be seen by the vehicle operator.
The AITS team then equipped the spotters with a High Visibility Vest (HVV)
and High Visibility Gloves (HVG), and the spotter became visible as were the
hand signals.
The vehicle operators could see the spotter and hand signals wearing the
HVV and HVG much better under all conditions. Therefore all emergency
responders should have an HVV to wear when they get out of the vehicle.
HVG only costs about $25.
To develop a backing procedure for your SOP, review the sample backing
procedures from the International Association of Fire Chiefs (IAFC) model
procedures. Your crews already have the HVV so it is just a matter of including
in the SOP that they must wear the HVV when acting as a spotter. Continue
to reduce the risk for the spotter by procuring the HVG and issuing them to
each person who may act as a spotter. You can greatly reduce the risk to
spotters and improve their effectiveness by implementing these procedures.
The Need for a Safety
Upgrade When Backing
issued the rule on March 31, 2014, requiring all new light vehicles including
SUVs, trucks and vans to have rear view visibility systems – basically backup
cameras. This rule will start phasing in on May 1, 2016, and will be 100% May
1, 2018.
Congress required this action as part of the Cameron Culbransen Kids
Transportation Safety act of 2007. Two-year-old Cameron Culbransen, for
whom the Act is named, was killed when his father accidentally backed over
him in the family driveway. (Extract from DOT proposal NHTSA 17-10, Dec.
3, 2010)
American Integrated Training Systems, Inc. (AITS) conducts EVOC Train
the Trainer (T3) Courses for fire departments, ambulance companies, medical
van companies and police departments nationwide, as well as in the Kingdom
of Saudi Arabia and American Samoa. None of the course materials included
the use or a Rear View Camera (RVC), and AITS needed to revise the backing
procedures as necessary to inclue the use of a RVC. Meanwhile, backing
procedures trainings involving the vehicle operator, spotter, use of standard
hand signals by the spotter, use of mirrors, location and visibility of the spotter
and actions to take when the spotter are very important. Backing procedures
should be described in the organization's Standard Operating Procedures
(SOP) and include the integration of a RVC when the organization has them
on their vehicles.
AITS conducted a literature search to determine if there were existing
procedures for using the RVC during backing operations, and what Standard
Operating Procedures (SOPs) had to say about the use of RVCs. As a base
reference we went to the U.S. Department of Transportation, Emergency
Vehicle Operator Course (Ambulance) Instructor Guide and it had excellent
procedures for backing including the necessity for using a spotter but did not
discuss the use of an RVC. The International Association of Fire Chiefs (IAFC)
has a model SOP on their website (IAFC.org/vehiclesafety). The IAFC model
SOP describes backing procedures using at least one spotter even when
you have an RVC. In fact, a spotter is required for all backing operations.
The internet literature search found several other SOPs that echoed the U.S.
Department of Transportation (USDOT) and IAFC SOP. The SOP polices for
backing also encouraged vehicle operators to position their vehicles, when
possible, so that backing would not be necessary. Every SOP that AITS
reviewed required a spotter when backing except in those rare instances
when a person is not available to act as a spotter. The procedure to be used
when no spotter is available is for the vehicle operator to walk around the
vehicle and make sure that there are no obstacles and then back with caution.
Rear View Cameras
The US Department of Transportation National Highway Traffic Safety
Administration (NHTSA) estimates that, on average, 292 fatalities and 18,000
injuries occur each year as a result of back-over crashes involving all vehicles.
One of the fatalities that was investigated by the Centers for Disease Control
(CDC) involved two lifelong friends, one operating a fire apparatus and the
other acting as spotter. Sadly, the operator lost sight of the spotter but did not
stop. The apparatus continued backing, crushed and killed the spotter.
NHTSA proposed a safety regulation that was required by Congress to
phase in the requirement for all new vehicles less than 10,000 pounds to have
a Rear View Camera recently. This action was to be completed by September
2013 but has been delayed several times because NHTSA believes more
research is needed before it becomes a requirement. Fortunately, NHTSA
To develop a backing procedure for your SOP, review the sample backing
procedures from the IAFC model procedures. Your crews already have the
HVV so it is just a matter of including in the SOP that they must wear the
HVV when acting as a spotter. Continue to reduce the risk for the spotter by
procuring the HVG and issuing them to each person who may act as a spotter.
You can greatly reduce the risk to spotters and improve their effectiveness by
implementing these procedures. Now that we have taken the easy, low cost
actions to reduce backing risk, it is time to consider how to integrate the RVC
into the backing procedures.
The percentage of all emergency vehicles being equipped with an RVC
is increasing. For example, Mark Van Arnam, President/CEO, American
Emergency Vehicles, Inc. (AEV), stated that 34% of the 1,100 new ambulances
AEV produced in 2013 were equipped with a RVC. NHTSA estimated it would
cost about $58 to $88 to add a RVC to a vehicle that is equipped with a
Continued next page >
Backing Safety Continued
dashboard screen, and $159 to $203
for those without them. I added an
RVC to my SUV without a dashboard
screen. Cost for the camera and fiveinch display was $175 and another
$150 to get it professionally installed.
I feel that I have greatly reduced my
risk during backing and repairing even
a minor dent in the vehicle would cost
more than the camera system and
installation not to mention if I hit a
person. Many new vehicles now come with a RVC and some manufacturers
have stated that they will include an RVC on all new vehicles. The new NHTSA
Rule will not only get an RVC on all new vehicles but will prompt those who do
not have a RVC to have one installed.
AITS strongly recommends that all emergency vehicles and medical vans
have an RVC. Ambulances usually have a two-person crew and should use
a spotter when backing. But often the second person is too busy caring for
the patient to act as a spotter. Insuring that situation the ambulance operator
should get out of the vehicle and check the area behind the ambulance before
backing, then back very carefully. Having a RVC onboard would greatly
reduce the risk during all backing operations. When using a spotter, the driver
should follow the signals being given by the spotter by watching the mirrors.
The driver should crosscheck the RVC display but the mirrors and spotter are
the primary references.
The driver uses the mirrors as the primary reference with the spotter when
backing. If the driver loses sight of the spotter he must stop the vehicle until
the spotter comes back into view. n
Safety Communication
Contact Information
1. VP of Safety, Colin Henry
866-745-2445, 614-734-8047 or [email protected]
2. VP of Risk, Linda Hines
614-734-8024 or [email protected]
3. Infection Control Officer, Karen Swecker
614-734-8044 or [email protected]
Intranet Website Resources:
• Safety Awareness Form – The link to the form is located under
the Safety section
• Unusual Occurrence Form – The link to the form is located
under the Forms section then under Administrative Forms
• MedDebrief System – The link is found under the quick links
on the intranet and is automatically activated after a medical
transport
Dash mounted and rear
view mirror display
1. Safety Director, Jeff White
304-610-3666 or [email protected]
Rear view cameras come
in many different styles
and capabilities and can
be mounted in several
locations on the vehicle.
You can evaluate which
RVC system works best for
your type of vehicles and
operations.
2. Air Methods Sr. Director of Technical Safety, Don Lambert
412-398-0087 or [email protected]
3. Infection Control Officer, Nick Cooper
304-653-4025 or [email protected]
Intranet Website Resources:
The link is found on HealthNet WorkPlace under
Flight Team/Communicators tab.
SafetyMatters
America’s Medical Transportation Safety Newsletter
Do you have any ideas for SafetyMatters?
Let us know by emailing [email protected] or [email protected]