VAI Spotlight on Safety: Harnessing the power to prevent accidents A novel investigative approach helps operators prevent accidents by imagining them and analyzing their causes “in hindsight.” In an industry in which safety is paramount, helicopter operators constantly seek ways to protect their teams, passengers, and operations. Traditionally, this focus has involved postmortem investigations after a tragic accident prompts rigorous examination to identify failures. But what if we could gain similar insights without the tragedy occurring in the first place? That’s the promise of the “premortem” exercise—a proactive approach to safety that’s already proving valuable for companies such as air ambulance provider STAT MedEvac (click on this month’s Spotlight on Safety video, right, and poster, below, for more about STAT MedEvac’s exercise). A Serendipitous Turning Point For STAT MedEvac, the adoption of premortem exercises marked a turning point that began unexpectedly. “Midway through a typical leaders meeting,” recalls line pilot and check airman Glenn Shields, “our president and CEO, James Houser, interrupted the discussion and redirected us. He said, ‘I want to talk about everyone going home to their families every night.’ After a few moments of silence, one manager responded, ‘Perhaps we’re not talking about the right things.’ ” Recognizing the significance of the moment, Shields suggested the team try a premortem exercise. Based on Gary Klein’s work in prospective hindsight as explained in his 2009 book Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making, a premortem asks team members to imagine an accident that has already happened and work backward to determine what might have led to it. Despite the difficult nature of the conversation, the STAT MedEvac leadership team agreed it was necessary. Soon after, the company held a safety stand-down and a companywide premortem exercise. Overcoming Blame, Fostering Collaboration The premortem approach brings together team members from all areas—pilots, maintenance crews, medical crew members, and administrators—and encourages them to voice their concerns openly. Unlike a postmortem, which often brings blame, the premortem fosters a collaborative, blame-free environment. Shields describes it as “harnessing the power of prospective hindsight,” a process that allowed STAT MedEvac’s team to discover new risks and recognize strengths, creating a shared sense of purpose in safeguarding each operation. During their premortem exercise, STAT MedEvac simulated an accident scene complete with a realistic-looking overhead shot. The result was 734 responses identifying potential causal factors divided among 12 categories, including adverse weather, fatigue, a lack of resources, and ineffective maintenance, that continue to inform the company’s safety protocols. An added benefit of the premortem is the opportunity to stress-test the company’s ability to respond effectively despite the chaos that inevitably accompanies an accident. Most of us acknowledge that plans often change once the “first bullets start flying,” but try responding with no plan at all. A written emergency response plan (ERP) can offer some welcome calm during the storm. ERPs are critical, yet they often lack the attention they deserve until an emergency uncovers how woefully inadequate one is—if it even existed. Although STAT didn’t activate their ERP during their premortem exercise, Shields acknowledges that it would have provided an excellent opportunity to test the team’s response without the consequences of a plan breakdown. Every Voice Matters Engaging in “what-if” scenarios allows us to uncover insights that can prevent future incidents. By using premortem exercises to adopt a forward-looking mindset, operators such as STAT MedEvac are shifting from unfocused reaction to proactive prevention. “The method shows the team that authentic dissent is valued,” Shields says. “It’s a collaborative process that continues to guide our safety efforts and reminds us that every voice matters.” John C. Kenny, STAT MedEvac’s director of operations, concurs about the value of the premortem. “While I initially was skeptical about the value of conducting a premortem exercise, I was quite surprised by the results we obtained,” Kenny says. “In addition to the many obvious and predictable factors that anybody with aviation experience would recognize, the broad range of perspectives from our line employees shed light on some more-subtle and nuanced issues—issues that otherwise might have escaped notice until it was too late.” For helicopter operators considering this approach, premortem exercises offer a powerful tool to strengthen safety culture and anticipate risks. STAT MedEvac’s experience demonstrates that foresight and collaboration can provide the understanding needed to make sure every team member goes home safely, every night. We may not be able to predict our future, but with some honest self-reflection and a little collaboration, we can sure help make it a lot brighter. Chris Hill is VAI’s senior director of safety. Glenn Shields is a line pilot and check airman and Ronnie New senior manager of risk and safety at STAT MedEvac in West Mifflin, Pennsylvania.
