Oct 24 2019

Where’s Management? Posted 5 years 42 days ago ago by Randy Mains

“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 organization.

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 happed 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 the tail light striking 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 as well as 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 it 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 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 once the director got angry and took it out on the flight nurse I believe 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. Only going on the information you’ve given me, I feel it was handled inappropriately. I will also say you are 100% correct in being concerned 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 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, 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 you were told by management similar incidents were dealt with like this as a way to send the message that there are consequences for unsafe acts.  He is right, but punishing an honest mistake is not the answer. I am reminded of the saying, “The whippings will continue until moral improves.”

Unless there are details I am not aware of, I think your management was dead wrong to punish in this instance unless, of course, it was a willful, egregious or illegal act on the part of the nurse.  

Sadly, management missed a golden opportunity to demonstrate to the team they operate within a Just Safety Culture. I personally have not seen the damage, but helicopters don’t crash because a light cover has been damaged. In my view, management overreacted to say if the helicopter took off three people would be dead.  That’s scare tactics. Anyone who’s worked around helicopters for a while would understand that is just not so; saying it damages the credibility of the person making the statement.  

If management sent the flight nurse home because they thought that, after the incident, they wouldn’t have their mind on the job because of fear of being fired then I can understand it. But in a company with a Just Safety Culture that would not be a concern because team members know their job is secure even if they make an honest mistake.

You’ve stated the problem, now how to fix it? Your team needs to sit down with management to let them know that by not cultivating a Just Safety Culture, for the reasons outlined here, they open themselves up to what could be far more dire consequences in future.

Randy Mains is an author, public speaker, and a CRM/AMRM consultant who works in the helicopter industry after a long career of aviation adventure. He currently serves as chief CRM/AMRM instructor for Oregon Aero. He may be contacted at i[email protected]