Air Medical Journal 35 (2016) e1ee2
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Concern Network The Concern Network shares veriﬁed information to alert medical transport programs when an accident/incident has occurred. Both air and ground programs are encouraged to participate. The reports are shown here verbatim as they were ﬁled. If you have questions, contact CONCERN Coordinator David Kearns at (800) 332-3123 or [email protected]
4/4/2016 1500 EDT Life Lion Critical Care Transport M. S. Hershey Medical Center 500 University Blvd Hershey, PA 17033 Type: AS365N3 Tail #: N600LL Operator/Vendor: Hospital-owned Part 135 Weather: Clear. Not a factor Team: Pilot, Flight Nurse, Flight Medic. No injuries reported. No patient. Description: The aircraft had just undergone maintenance in the vicinity of the tail rotor (fenestron). The company's tool control program was followed ensuring all tools were accounted for prior to releasing the aircraft for ﬂight. In addition, the pilot conducted a thorough preﬂight of the aircraft as well noting no discrepancies. As the aircraft was turning up to return to its satellite base, one of the mechanics involved in the maintenance radioed the pilot and advised him to remain on the ground and shut down. After shutdown, maintenance notiﬁed the pilot that a ﬂashlight (Streamlight, box-light style) used during the maintenance was missing. A follow-up inspection of the aircraft by the mechanics located the missing light inside the fenestron on an obscured interior ledge. The light was removed and another inspection and tool inventory completed noting no discrepancies. The aircraft was returned to service without further incident. Additional Info: Despite implementation and continued emphasis on a comprehensive tool control program which includes shadowed tool boxes and mandatory daily and post-maintenance inventories, this incident still occurred. It occurred in part because the light involved was not part of the formal aircraft
maintenance toolbox enrolled in Tool Control. The reason the light was used was because it provided a generous amount of light for a sufﬁcient duration without rolling around like the ﬂashlight in the toolbox. The light was not positioned in the immediate area of the maintenance but was placed in an obscure void to provide line of sight illumination of a remote area being worked on. Furthermore, this light was placed without the knowledge of any of the other mechanics involved in the evolution. This, along with the use of a light not enrolled in the tool control program, effectively eliminated any error trap. Had the mechanic that placed the light not remembered at the last minute, the aircraft would have ﬂown with the light still present. Fortunately, the placement of the light did not present a hazard to any ﬂight control or any component critical for ﬂight. A Hazardous Report was submitted by the company Director of Maintenance and an investigation/review was completed by safety and administration personnel. This incident has been thoroughly discussed with all concerned highlighting the need for increased vigilance whenever the inevitable situation arises necessitating the need to use items during maintenance that are not enrolled in the formal tool control program, i.e. consumables, rags, etc. Furthermore, because of the usefulness of this style of light, a dedicated Streamlight for aircraft maintenance will be enrolled in our Tool Control program. This incident also illustrates the criticality of effective communication between all. Fortunately, the mechanic's quick action prevented the aircraft from taking off with a box-light adrift aboard the airframe. Source: J. Shouey, Life Lion Aviation Safety Ofﬁcer
4/18/2016 0700 C Life Link III Type: AgustaWestland 119Kx Weather: Clear. Not a factor Team: Pilot, ﬂight nurse, and ﬂight paramedic. No injuries reported. No patient. Description: Pilot found evidence of a bird strike while conducting a post ﬂight walk around. No indication of a bird strike during ﬂight by the pilot or clinical crew. Bird strike resulted in minor damage to nose cone and aircraft out of service time. Aircraft Maintenance Technicians collected bird remains in clean zip lock bag. Life Link III completed FAA wildlife strike report and bird remains were sent to the Feather Identiﬁcation Lab at the Smithsonian Institution in Washington, D.C. Additional Info: For more information about the FAA wildlife strike program and resources, see the below links: http://wildlife.faa.gov/strikenew.aspx http://wildlife.faa.gov/birdremains.aspx http://www.faa.gov/documentLibrary/ media/Advisory_Circular/150_5200_32b. pdf Source: Joseph Hennessy, Safety Manager
5/9/2016 16:40 Lurie Children's Hospital Transport Team 225 E. Chicago Ave Chicago, IL 60611 Model: 2016 Ford E350, Medix Emergency Vehicles Type: Type III Weather: Clear. Not a factor Road: Wet Team: EMTx2, RNx2, and RRT. No injuries reported. No patient.
Concern Network / Air Medical Journal 35 (2016) e1ee2
Description: As the ambulance slowed down to turn into their destination, a taxi was over the middle white dotted lane line and tried to pass the ambulance on the left and struck the
ambulance in the driver's side rear of the vehicle. No injuries sustained, vehicle operable, and minor cosmetic damage. All crew members were fully restrained.
Additional Info: Team was able to continue on to pick up child and transport back to Lurie Children's Hospital. Source: Brenda Westberg, RN, C-NPT Manager PCO Critical Care Transport