NATA Safety 1st eToolkit – Issue 51 – April 17, 2009 Page 1

NATA Safety 1st eToolkitNATA Safety 1st eToolkit

The NATA Safety 1st Management System (SMS) for Ground Operations is underway and many of the tools discussed in this and other eToolkits will be provided to SMS and PLST participants.

Welcome to the 51st issue of the NATA Safety 1st eToolkit, our monthly online safety newsletter, supporting the NATA Safety 1st Management System (SMS) for Ground Operations.

This monthly newsletter highlights known and emerging trends and environmental and geographical matters, as well as advances in operational efficiency and safety. Flight and ground safety have been enhanced and many accidents prevented because of shared experiences.

Applying Lessons Learned From Commercial Aviation By: Joe Brown, MAS, ATP, CFI, CFII, MEI www.thesalusnetwork.com joe.brown@thesalusnetwork.com Commercial aviation has an impressive safety record. Over the past decade, the focus on implementing system safety design principles as sound management practices has become more commonplace. Other factors that have enhanced safety in aviation have included the use of non-technical skills such as Crew Resource Management (CRM), technological advances (i.e. air traffic collision avoidance systems, global positioning systems (GPS), etc.), and improved aircraft and human factors design. Together, these changes have contributed to significant reductions in overall aviation accident rates. However, in any industry, regardless of the safety statistics, hazards and risks that could lead to adverse events always exist. Other high-risk, technologically advanced industries such as healthcare, police, marine, fire, rail and others can also benefit from the many years of safety management lessons learned in commercial aviation. To illustrate, the critical components of CRM (the focus on team training, group interaction for decision making, performance improvement processes, and the interaction of human factors within high risk, high stress environments) have relevance and applicability in health care. CRM programs (principles) have been implemented in operating room environments and for team training. Learning from the aviation industry,

healthcare leaders and others in high-risk industries can transform adverse event statistics through a global paradigm shift that migrates toward system-wide safety improvement, error reduction, and improved operational efficiencies. A system safety perspective includes oversight and adoption of safety management protocols. The intent of this approach toward safety management is for all high-risk industry constituents to work together to produce a viable, evidence-based, integrated system safety solution.

Issue 51 April 17, 2009

In This Issue: ► Applying Lessons Learned From Commercial Aviation………….1 ► Regulatory, Legislative & NATA News…………………………….6 ► Safety Corner – Dealing with: It Won’t Happen to Me……….....8 ► Incident Roundup…………………………………………………….9 ► Education Corner.………….………………………………….…...12 ► Continuing Education………………………………………………17 ► PLST Order Form…………………………………………………..18 ► NATA SMS for Ground Operations………………………………20 ► NATA’s 2009 Board Members …………………………………...21

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitSystem Safety and Its Application in Other Industries Historically, safety has been thought of as an organization’s “highest priority” or as “something in which to strongly believe.” Traditional safety management has primarily focused on internal auditing, reporting, and investigating events that have already occurred. These are indeed important functions, but what is lacking is a fundamental and practical understanding of what safety actually is. More importantly, the focus needs to be on how to manage safety from a system’s point of view in order to address root causes rather than symptoms of problems. Simply put, safety is freedom from harm. Or, more specifically, safety is the minimization and management of operational risk to lower, more acceptable levels. System safety is “the application of special technical and managerial skills in a systematic, forward-looking manner to identify, analyze, assess, and control hazards and risks within our organization.” It is very important to point out that this definition does not apply to operational matters alone. Risk exists at all levels and functions of an organization from finance to housekeeping… Under system safety, the organization is no longer viewed as individual departments or processes. Rather, system safety takes a more holistic, interactive approach in terms of how individual departments and processes work together in the overall system. Safety, or more appropriately stated, safety management, is seen as an integral component of a system where system failures are analyzed and processes and hazards are effectively identified and controlled. The Salus Network has created a “System Safety Architecture” that visually describes the functional components of a system: the operational system itself, its supporting sub-systems, and all associated working level processes or elements. The resulting framework allows for better identification, understanding, and management of safety (risk) at usable levels. Attempting to collect useful data at the system or sub-system level is not practical as these system levels are too broad to generate meaningful data. Instead, the focus should be on working level procedures and processes, or elements, in each sub-system since these areas represent a point in a system that allows for easy data collection and data dissemination. To illustrate, any typical management system in an organization will, or should, have structure. For example, all organizations have an internal finance system that has several sub-systems (i.e. financial programs and procedures) and subsequent working level processes or elements, each with a definitive structure. These elements serve as a primary data source through which data is collected, analyzed, managed, and disseminated. Visually, the structure appears as follows:

• System: Finance Management ⇒ Sub-System: Financial Programs and Procedures

• Element: General Accounting Principles • Element: Procurement • Element: Payroll • Element: Budget

System safety architecture, as an organizational design philosophy, is no different. The first step required in system safety is to identify all the operational systems in an organization (i.e. business units, service lines, departments, etc.). The Federal Aviation Administration (FAA) has done this already for 14 CFR Part 121 Commercial Airlines in their oversight methodology known as ATOS (Airline Transport Oversight System). By defining operations from a system perspective, it is now possible to identify each operational system, supporting sub-system, and specific working level process (element). Two examples, one from aviation and one for healthcare, are provided below:

• System: Flight Operations Management ⇒ Sub-System: Air Carrier Programs and Procedures

• Element: Deicing Procedures • Element: Airman Duties / Flight Deck Procedures • Element: Operational Control • Element: Aircraft Performance and Operating Limitations

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NATA Safety 1st eToolkitNATA Safety 1st eToolkit• System: Medication Management

⇒ Sub-System: Medication Administration • Element: Procuring and Storing • Element: Preparing and Dispensing • Element: Administration • Element: Monitoring

By defining an organization in this systems-based, architectural manner, all working level processes (elements) can be displayed clearly. This allows the system to be effectively analyzed from an operational risk standpoint. Each identified working level process (element) serves as a data collection / data distribution point. These processes (elements) can be used to assess and monitor operational efficiency and overall system performance in terms of safety and risk. Transfer of Technology Recently, The Salus Network has had success in the transfer of technology from the commercial aviation industry to healthcare. By utilizing System Safety Architecture, it was able to apply defined system safety attributes as an assessment methodology to assess the medication administration process of a regional hospital located in the northeastern United States. Parallels between both industries (aviation and healthcare) were immediately identified such as team work, change of shift handoffs, documentation, etc.

Safety Assessment Methodology The safety assessment methodology used at the hospital contained specific pre-assessment activities and specific task modules very similar to those used in commercial aviation. Pre-assessment activities were designed to identify the hospital’s management system and gain a sound working knowledge of the policies and procedures for the medication management system. Specific objectives of pre-assessment activities included:

• Identification of clear process ownership (i.e. responsibility and authority); • Obtaining an understanding of the management system (i.e. reporting relationships, lines of authority, etc.);

Review of the documentation system to determine how medication management policies and procedures are structured and disseminated to frontline personnel.

The on-site safety assessment consisted of 40 hours; the assessment was conducted by the consultant over all work-shifts and included two weekends. The initial stage of the assessment was an open meeting with leadership. Additional meetings were held with the managers and staff on the medical and surgical units selected for the review. They were informed about the data to be collected, the time frame for the assessment, and the reporting process for identification and prioritization of risk into high, medium, and low classifications. Data collection included assessment of the hospital medication management system processes against commercial aviation-based system safety attributes (responsibility, authority, procedures, controls, risk-point process measurements, and interfaces) in accordance with the following:

• Responsibility – Is there a clearly identifiable, qualified, and knowledgeable person who is accountable for the quality of the process? In other words, who’s in charge?

• Authority – Is there a clearly identifiable, qualified, and knowledgeable person with the power to establish and modify the process?

• Procedures – Are there clearly developed procedures and processes that answer who, what, when, where, and how type questions?

• Controls – Are checks and restraints designed into a system to ensure a desired result is achieved? • Risk-Point Process Measurements – Does the organization regularly assess its processes in order to

identify and correct problems or potential problems?

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitInterfaces – Are processes coordinated between clinical and administrative disciplines? On-site activities included direct observations (all work-shifts) and review of pertinent documentation such as physician orders, medication administration records, and nursing notes. Interviews were held with key frontline and management personnel including senior management (chief nurse executive, chief medical officer, and chief quality officer), nursing personnel (managers, assistant managers, and staff nurses), nursing instructors, pharmacy personnel, hospitalists, and information technology personnel. The objectives of the on-site assessment were to determine if:

1. The medication management system design incorporated defined safety attributes to ensure safe operations; 2. Documented policies and procedures were followed by all personnel; and, 3. The medication management system worked as planned.

The safety assessment also sought to determine regulatory compliance with applicable Joint Commission (healthcare’s version of the FAA) and other oversight agency standards. Safety Assessment Outcomes Seven sub-systems and 43 working-level processes within the medication management system were identified through the safety assessment. Opportunities for improvement were identified in each medication management sub-system. A sampling of changes recommended for the hospital include: Organization and Management

• Establish clear ownership (responsibility and authority) for the medication management system. • Implement cross-functional process mapping for all critical processes. • Conduct a bi-annual review to ensure system integrity, safety, and quality.

Documentation and Records Management

• Consider an enterprise-wide document management system in order to manage and control all hospital documentation centrally. Consideration should be focused on achieving a standardized document naming and numbering convention; content consistency across documents; interdisciplinary document revision and control process; and other factors associated with document management such as, document currency, distribution channels, and availability.

• Incorporate system safety attributes (responsibility, authority, procedures, controls, risk-point process measurements, and interfaces) into all processes containing procedures.

Medication Administration

• Design a standardized “end-to-end” medication administration process beginning with process ownership (responsibility and authority) paying specific attention to “a day in the life of a patient.” Effort should be made to structure the standard of care from patient admission to discharge.

• Centralize the medication administration function in terms of control and reliability. For clarity, this activity is similar in concept to airline maintenance control whereby all aspects of aircraft maintenance, including parts, are centrally managed. Each aspect of an aircraft’s maintenance follows strict planning, scheduling, and execution to maintain the highest levels of control and reliability.

• Consider implementing a sterile communications environment when administering medications such as a quiet room or creation of visual symbols indicating medication administration in progress.

Medication Reconciliation

• Reinforce a standardized definition of medication reconciliation throughout the continuum of care. • Consider assigning the Pharmacy Department ownership responsibility of this critically important process as

pharmacy personnel are considered the primary, in-house subject matter experts on medication. • Validate consistent, accurate patient medication reconciliation throughout each patient interval (admission, in-

patient stay, and discharge).

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitMedication Technology

• Consider the use of an electronic bedside verification system such as bar-coding or radio frequency identification (RFID) as budget permits.

• Further enhance the interface capabilities of both existing and future information technology applications. Education

• Adopt an interdisciplinary CRM education program. Special emphasis should be placed on identifying expected work behaviors in each core hospital process and providing the non-technical tools (i.e. effective communication, team-building, workload management, technical proficiency, situational awareness, conflict resolution, and leadership) to enhance safety and operational efficiency.

Safety Management

• Implement a comprehensive, data-driven, evidence-based, safety management system (SMS). An effective SMS allows a healthcare organization to manage operational risk systematically across the entire system safety architecture.

• Establish risk-point process measurements for each identified working level process associated with the sub-system depicted in the system safety architecture diagram. Risk-point process measurements serve as the origin for a robust internal evaluation program. This provides the organizational basis to manage safety, improve operational efficiency, and achieve “inspection readiness” related to the Joint Commission, state, and other regulatory / oversight authorities.

Risk-Prioritization Framework Recommendations that emanated from the safety assessment were organized into a risk-prioritization framework that included risk definitions used in commercial aviation. Risk prioritization was determined on the following classification criteria:

• High Risk = A high likelihood that a failure in a particular process could cause a potential loss (or breakdown) of an entire system or sub-system possibly resulting in an adverse event or serious unsafe condition.

• Medium Risk = A moderate likelihood that a failure in a particular process could cause a partial breakdown of a system or sub-system possibly resulting in violation of regulations or hospital rules, which may lead to an unsafe condition.

• Low Risk = A low likelihood that a failure in a particular process could cause poor system or sub-system performance possibly resulting in an unsafe condition.

An additional consideration for the generation of the risk-prioritization framework was the degree of implementation difficulty (i.e. cost factors to implement change, resource requirements, time to complete, etc.). Safety Culture Any industry, including healthcare, can improve its safety culture by incorporating system safety principles. Culture, in general, is most commonly understood as “the way we do things around here.” Cultural issues can be expanded to consider implications of other factors that impact safety and operations. Regulatory and professional requirements are often misinterpreted or superimposed on the organization’s safety culture. Implementing system safety on an organization-wide level combats this issue because the organization is able to define work practices and behaviors in a clear and concise manner. This allows frontline personnel to understand better what is expected of them when performing their duties instead of simply relying on individual or professional experience. Thus, the use of “work-arounds” is significantly reduced, allowing safety culture to advance in a positive direction. Outcomes Results of the safety assessment led to categorization of risk areas as high, medium, or low. These results were presented to the hospital senior executive team. Based on these results, plans are being developed to engage in a full medication management review, from procurement to monitoring and evaluation of effectiveness.

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitConclusion The medication management system safety assessment performed at the hospital demonstrated the immediate and valid applications of system safety and its accompanying safety management strategies. As proven in the commercial aviation industry, system safety and its associated safety management tools and strategies are an excellent organizational protocol for improving safety, reducing risk, and enhancing operational efficiencies. Organizational leaders in any industry must ask the following question. If the most technically competent employee leaves the company, does any operational system degrade? The answer is most likely a resounding “yes” if the organization is lacking a fundamental, systems-based approach to safety management and process design. System safety moves away from traditional thinking in that effective organizations no longer rely primarily on individual talent to form the basis for high-quality, safe operations. Rather, effective leaders tap into their talent to improve organizational processes from a systems-based perspective, thereby continually improving operations. This qualitative safety assessment of the hospital’s medication management system clearly demonstrated the value of applying the safety management lessons learned from commercial aviation. The transfer of technology (system safety) was determined to be immediate and impactful. Clearly, all high-risk industries can benefit from commercial aviation’s safety management practices without the need to “reinvent the wheel.” It is important to remember that safety must be designed into operations, not inspected into them. Article References:

• Medication Administration Process Assessment: Applying Lessons Learned from Commercial Aviation. Journal of Nursing Administration (JONA) February 2009, volume 39, pp. 77-83.

• Oriol MD. Crew resource management: application in healthcare organizations. Journal of Nursing Administration (2006). Volume 36, pp. 402-406.

• Powell SM, Hill RK. My copilot is a nurse – using crew resource management in the OR. AORN J. 2006; 83: 179-206.

• Marshall DA, Manus DA. A team training program using human factors to enhance patient safety. AORN J. 2007; 86: 994-1011.

• McConaughey E. Crew resource management in healthcare: the evolution of teamwork training and med teams. J Perinat Neonatal Nurse. 2008; 22: 96-104.

• Federal Aviation Administration. Flight Standards Information Management System. Volume 10: risk management. Chapter 1: general. Section 5: acronyms, abbreviations, 10-78 terms, and definitions, system safety.

• Federal Aviation Administration. Flight Standards Information Management System. Volume 10: air transportation oversight system. Chapter 1: general. Section 2: introduction to ATOS business process and tools.

• Federal Aviation Administration. Flight Standards Information Management System. Volume 10: air transport oversight system. Chapter 3: Risk management process. Section 1: Risk management processes, 10-341 analyze and assess risk.

• The Joint Commission Patient Safety Solutions (2008). REGULATORY, LEGISLATIVE & NATA NEWS Employee Free Choice Act Introduce; NATA Releases Action Call in Opposition to Legislation Democrats in both the U.S. House of Representatives and the U.S. Senate introduced controversial labor legislation, the Employee Free Choice Act, in both

chambers on March 10, 2009. H.R. 1409/S. 560, also referred to as "card check," would change how unions organize workers in the United States by eliminating a company's right to demand a secret ballot if a majority of employees sign authorization cards to form a union. It also requires binding arbitration to reach a first contract, if labor and management can't reach an agreement

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitwithin 120 days, and increases penalties for businesses that violate labor laws. The bill passed the House in 2007 but stalled in the Senate. Instead of an election run by the National Labor Relations Board, workers would be able to fill out cards saying whether they support or oppose a union. Big labor unions like the American Federation of Labor-Congress of Industrial Unions (AFL-CIO), Service Employees International Union (SEIU), and the Change to Win Coalition spent millions of dollars during the 2009 election, and are pushing Congress to approve this legislation. The U.S. Chamber of Commerce and other pro-business groups are working in opposition to the legislation. U.S. Senator Arlen Specter (R-PA) announced last week that he will oppose invoking cloture on the card check bill, a decision that denies Democrats and labor unions a 60th vote to overcome a Republican filibuster. Specter feels the better way to expand labor's clout in collective bargaining is through amendments to the National Labor Relations Act rather than through eliminating the secret ballot and mandating arbitration. Specter voted for cloture when the Senate considered the bill in 2007, but he stated that the economic crisis prompted his decision on this bill. Companies such as Starbucks, Whole Foods and Costco announced last week they were forming the Committee for a Level Playing Field and, with the backing of Democratic operative Lanny Davis, would set out to publicize six principles for labor-law reform that provided an alternative to card check legislation. NATA members: Click here for talking points on opposition to the card check legislation. Special Message From NATA President James K. Coyne: The Worst Strategy There are many things to be afraid of these days, but nothing scares me more than the widespread use of the phrase “hunker down.” Government officials, CFOs, and pundits offer these gutless words as a commonsense strategy for America during these difficult times. A terrible hurricane is passing over the land, they say, and no one knows when it will be safe to come out. Hunker down, take your bailout money, and be quietly grateful. Nonsense! Whatever happened to the ‘land of the free and the home of the brave,’ not to mention that ‘can-do’ attitude

that has defined our national spirit for over two centuries? Is it time to retire the American eagle and put a groundhog on our coins? President Reagan faced a severe recession when he came into office, but I’m sure the thought of hunkering down never crossed his mind. The nation needed more economic activity, but he knew that ‘government activity’ was an oxymoron and recovery would only come when the private sector, by its own initiative and with private capital, was inspired to invest, grow, compete, build, hire, and fight its way back to prosperity. Private sector initiative was a phrase he often used, and the eighties proved it to be a far better strategic plan than hunkering down and waiting for salvation to trickle down from Uncle Sam! Rather than hunkering down, American businesses need to get off their butts, ignore most of the claptrap in Washington, and do what they know how to do: create, sell, deal, and get moving again. And what better time to do it than when many of your competitors are drinking the ‘hunker down and wait for the bailout to work’ Kool-Aid that big government is selling. This is exactly not the time to cut back on marketing, exactly not the time to sell the corporate jet, exactly not the time to cancel conventions, exactly not the time to scale back bonus programs, and exactly not the time to hunker down. This is one of the greatest entrepreneurial opportunities in history. Your customers need your ideas and innovation more than ever before. Hunkering down tells them you are afraid and out of ideas. Isn’t it better to show them that now is the time to work together to expand market share (competitors are cutting back), that now is the time to develop new programs (costs are lower), and that now is the time to make strategic acquisitions (remember ‘buy low, sell high’)? The best thing about not hunkering down is that you’ve already paid for it. You already have your equipment, your staff, and your ideas – just get out and use them. If you really believe that your company’s greatest asset is its people, why not show them how to be more active, more aggressive, and more ambitious? After all is said and done, only initiative and activity will rebuild your business – hunkering down is for wimps. One synonym for hunker down is squat. As a business strategy, that’s exactly what it’s worth.

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitFrance Hired As Manager, Regulatory Affairs NATA recently announced the hiring of Michael E. France as its new manager, regulatory affairs. France, who attended Ball State University, previously worked with Volo Aviation in Manassas, VA, as a quality control and training coordinator. During his tenure at Volo Aviation, France was responsible for regulatory compliance issues and the development of operational manuals. Prior to Volo Aviation, France worked as the lead line service technician/quality control inspector for Next Flight Aviation in Manassas, VA.

As the association's manager, regulatory affairs, France will be responsible for handling issues that affect the association's FBO and general aviation airport members as well as all environmental matters.

"Mike is a welcome addition to the NATA government and industry affairs team," explained Eric R. Byer, NATA vice president of government and industry affairs. "His experience working for our member companies on regulatory compliance issues and environmental matters is truly invaluable," Byer commented. "Mike knows first-hand how issues affect our membership and how to confront the issue best going forward."

"We are truly fortunate to have someone of Mike's caliber join the NATA government and industry affairs team," concluded Byer. "He will have an immediate impact in advancing our regulatory agenda."

SAFETY CORNER Dealing with: “It Won’t Happen to Me” They may not say it aloud, but you know one of the primary reasons some employees don’t follow safety rules is because they think, “It won’t happen to me.” One way to counter that thought: Arrange to have employees hear important safety messages from a number of different sources. A new report from the National Weather Service (NWS) backs that up. The NWS just released its internal report on the Super Tuesday tornado outbreak of Feb. 5-6, 2008. The report’s subtitle: Why Some People Don’t Heed Severe Weather Warnings. The reason is many people minimize the threat of personal risk through “optimism bias,” the belief that such bad things only happen to others. This optimism bias was reflected in comments from several affected residents in the report, such as, “They [tornadoes] always seem to hit down the road,” and “We didn’t think it was going to be here.” The following is a prime example: A woman in Arkansas heard a tornado warning from the local TV news and then from a local radio station. Warning sirens sounded twice. Only after her son-in-law called did she decide to take shelter. The NWS theorizes that an important factor in how people respond to warnings is whether they personalize the threat. This example shows how some people require multiple sources of information to assess personal risk. But there is good news. You don’t have to be the only one to repeat safety warnings to workers. Getting others to do it will help. How can you do this?

Get outside expert speakers to address employees. Use other sources of information - such as this Web site - to back up your points. Make it really personal: Have an accident victim speak. If one isn’t available, ask workers how their lives would be

affected if they were injured.

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitINCIDENT ROUNDUP A Canadair CRJ-200 aircraft’s left winglet struck a fuel truck while being pushed back from the gate. No injuries were reported and damage to the aircraft and truck are unknown. Lineman Admitted To Not Following Proper Procedures A lineman's confusion appears to have been behind the January 2009 emergency landing of a Cessna 421C Golden Eagle in Wichita, KS, according to the National Transportation Safety Board's factual report on the mishap. According to the report, the piston-engined twin departed Wichita's Colonel James Jabara Airport (AAO) shortly after 8:00 am local time January 30, bound for Millard Airport (MLE) west of Omaha, NE. It didn't take very long for problems to arise. "During takeoff, the pilot noted 2,800 rpm, 39 inches of manifold pressure, and all engine instruments were 'in the green,'" the report states. "While climbing to 3,000 feet mean sea level, the airplane's engines began to lose power. The pilot noted propeller rpms were still 2,800 but felt as though no "power" was being produced by the engines; the pilot coordinated for an emergency return. While attempting to troubleshoot the malfunction, the pilot assessed that he could not return to the airport and elected to perform a forced landing." The aircraft landed gear-up in a field. The pilot and his two passengers suffered minor injuries, but came through the scrap relatively OK. Investigators arrived on-scene soon after... and it didn't take them long to find a problem. "An examination of the airplane revealed that the fuel tanks contained what appeared to be a mixture of 100 low-lead (100LL) and Jet-A fuel," the NTSB says. When questioned by FAA inspectors, a lineman at AAO admitted he topped off the Cessna 421 with 80 gallons of Jet-A, not 100LL. He then offered an interesting explanation. Two Piper PA-46 turboprop conversions were also based at AAO at the time of the incident. Those aircraft are not required under the JetProp STC to have modified fuel filler ports, those with larger openings to accommodate flattened Jet-A fuel nozzles; an adapter is used to move fuel into the narrower Malibu-spec opening. However, the lineman told investigators that FBO personnel had discovered a work-around: by rotating the nozzle, and dispensing fuel at reduced pressure, one can leave the adapter in the truck. "This method became the normal way for the accident line person to refuel the two converted PA-46 airplanes," the NTSB states, "so the line person reported that he incorrectly thought the accident airplane required Jet-A fuel despite having refueled the accident airplane several times previously." The NTSB notes the 421 had narrow fueling ports required by an airworthiness directive, specifically intended to prevent the kind of error to which the lineman admitted. The Cessna 421's basic fuselage is shared with the turboprop-engined Cessna 425 Conquest I; several 421s have also been converted to turboprops. The report notes the pilot conducted a "normal" pre-flight inspection ahead of the accident flight. He had asked the FBO to top off the tanks upon landing at AAO the night before. Click here for the NTSB Factual Report

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitAn American MD80 Incident 01/08/2009 at LAX

After pushback from the gate, the pilot throttled up to taxi before the tractor and tow bar were disconnected

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NATA Safety 1st eToolkitNATA Safety 1st eToolkit

More on pushback from the gate, the pilot throttled up to taxi before the tractor and tow bar were

disconnected

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NATA Safety 1st eToolkitNATA Safety 1st eToolkit

EDUCATION CORNER NATA’s 139 Fire Safety Training Options NATA’s Safety 1st Program offers an online fire safety training course that is certified by the Federal Aviation Administration (FAA) in accordance with 14 CFR Part 139 Section 321 (139.321). This training is required for all aviation fuel handlers every 24 calendar months. And even better, this certification is offered as a stand alone fire safety training course or as one module of an in-depth eight-module line service training program.

www.nata.aero/plst Why did we take just one module from NATA’s dynamic Safety 1st’ Professional Line Service Training (PLST Online)? The stand alone 139 site was built to meet the fire safety training needs for NATA’s Line Service Supervisor Training (LSST), Advanced Line Service Supervisor Training and NATA’s Line Service Technician Boot Camp Seminars. Many companies that provide services to the airlines or want refresher fire training take advantage of this FAA-approved fire safety training course as well.

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NATA Safety 1st eToolkitNATA Safety 1st eToolkit

https://www.139firesafetytraining.com/index.php In addition to the vast fire training on NATA’s 139 site, students share comments and experiences on forums so that lessons may be learned about what happens on other ramps. Here’s what is being shared on our 139 forums… “A military aircraft had just started his #2 engine. Fire shot out of his exhaust (30 feet) which ignited fuel from weep tubes at the rear of the aircraft. The lineman signaled the pilot (figure eight). They shut the engines down. The fire in the exhaust went out but the ramp was burning from the dripping fuel (weep tubes). The lineman was near an extinguisher and put the fire out.” “A fire can happen at any time when dealing with fuel, if [your staff is]not properly trained. All of our guys have to go though NATA Safety courses before they can work on the flight line.” “Luckily there are not too many occurrences like what happened in Denver. It is great to have the training but don't really want the experience. I didn't get into this industry to fight fires but I do want to prevent them and protect the lives of the workers.” “Unfortunately, fire is a real threat we have to deal with on a daily basis in this industry we work in called AVIATION. Fortunately, we have never had a fire, but the threat is always there in aircraft fueling and aircraft maintenance. All anyone can do, if faced with an unexpected fire, is [to] rely on his or her proper and recurrent training received from a course like this or similar, along with live training exercises.” Whatever your fire safety training needs are, NATA strives to meet them through various options. Do you need fire safety training as a stand alone training program? Check it out at https://www.139firesafetytraining.com/index.php. If you are looking for in-depth line service training as well as fire safety training, go to www.nata.aero/plst. NATA’s Education Week Scores A Jackpot NATA’s Education Week seminars and workshops were well attended and drew many enthusiastic comments from participants. Energetic, awesome, interesting, engaging, enjoyable, useful, realistic and applicable were just some of the adjectives used to describe the training. Attendees particularly enjoyed the new LSST format and the 2009 speaker lineup. We would like to recognize and thank the following seminar/workshop sponsors: McBreen & Kopco, ServiceElements, Ascent Aviation Products, and Western Petroleum Company.

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NATA Safety 1st eToolkitNATA Safety 1st eToolkitStephen Hopson, the first deaf instrument-rated pilot, delivered his uplifting and inspirational story to a full house. Stephen is a past recipient of one of NATF’s scholarships, which helped fulfill his dream of becoming a pilot. His enthusiastic message to the audience was: Despite overwhelming odds, you too can achieve your dreams. We thank Sensear for their sponsorship of this presentation.

NATA co-hosted a reception for all attendees/exhibitors on opening day, attracting hundreds to our booth, and held several drawings for free PLST Online training over the three days of the Expo. Congratulations to the following winners of free PLST Online training: Jeremy Sobolik, Fargo Jet Center Steven Levesque, Hawthorne Corp. Greg Cash, Air 51

How to Build a More Successful FBO – Coming to Windsor Locks May 14-15th and Baja, Mexico, October 27-28th Running and managing an FBO is demanding enough without the addition of today’s unprecedented economic conditions. So, what are you going to do? Open the window and yell, “I’m mad as hell, and I’m not going to take it any more!” Well…you may feel better, but what you are left with is reality and a dire need to take care of business -- NOW. Come join our industry experts who’ve been there, done that and have nearly 100 years of combined experience in the FBO business. You’ll benefit from the wisdom of what to do during tough times, how to decrease credit

card rates, lower insurance premiums, find and retain top talent, strengthen your fuel provider relationship, negotiate favorable lease agreements with your airport authority and build long-term profitable customer relations, plus many more ideas that will put your business on track for future success. You will spend time networking with your comrades during the popular round table discussion of best practices. You’ll walk away amazed by what others are doing and go home with some great ideas to put into action. As Andi and Dan Montgomery with Montgomery Aviation said of last year’s FBO Success seminar, “…We have attended other FBO programs in the past but this was by far the best! …The interaction with the other FBOs went beyond amazing!

NATA Safety 1st eToolkit – Issue 51 – April 17, 2009 Page 15

NATA Safety 1st eToolkitNATA Safety 1st eToolkitHere’s a sneak peek at one of the many great topics that you’ll experience during this unsurpassed seminar… Building Long-term Profitable Customer Relationships The process of building long-term profitable customer relationships necessitates an investment of time and hands-on management. It requires a commitment to understand your customers' needs, requests and desires. It also requires exemplary leadership and empowerment of employees from the bottom up. We'll break down the various elements that will make customers your best friends and illustrate that FBOs of any size can get their share of business. Part I: Making the Customer Your Best Friend Building long-term profitable customer relationships is the lifeblood of an FBO. We'll show you ways to add value without lowering fuel prices.

Take care of your current customers first. Replacing an existing customer takes not only time, but money.

Manage your brand. What do you do to make sure your brand image is strong and represents a good value?

What's your Social Quotient ™? Learn the one question to ask customers that will tell you if they are going to be a long-term profitable customer or just a flash-in-the-pan.

Part II: Marketing and Communications for Any Size FBO There are many ways to "shake hands with the customer." You don't have to be a large FBO to get your share of business.

What's your Buzz Quotient ™? Are you "on the radar" - does your next new customer even know you exist?

There are many cost effective ways to communicate or "shake hands" with your customer. We'll discuss various channels of communications that won't break your budget.

Develop a communications checklist. We'll discuss what's most important and what's least

important to build your FBO image and awareness.

A Bargain! Whether you join us in Windsor Locks, CT, at the mesmerizing New England Air Museum on May 14-15 or an unbeatable cruise in Baja, Mexico, October 27-28, you’ll get your money’s worth and then some. Make sure to look into the details on our Web site at www.nata.aero and click on our Events Calendar. This will be one investment that will continue to pay dividends throughout your FBO’s journey to further success. Register for 2009 Air Charter Summit and FBO Leadership Conference Now Today, "open for business" doesn't just mean open doors. It also means open minds, open ears and open arms. Businesses are inspired to explore new and creative ideas and solutions. They are listening to what is going on in their business environment and embracing change for the better. NATA's 2009 Air Charter Summit and 2009 FBO Leadership Conference provide two opportunities to hear about the regulatory landscape straight from government officials, get the latest intelligence tactics and strategies from nationally recognized experts, be inspired, find new solutions to current business challenges, and enjoy good company and entertainment. Conference Program Designed to Provide the Tools to Help Improve the Performance and Profitability of Your FBO Managers and senior-level executives of fixed base operations and vendors are invited to attend top-notch sessions, including a panel on the future of aviation manufacturing, rebutting the public and media blitz on business aviation, marketing to the Ritz Carlton standard and clientele, a TSA aviation security update, an FAA airports office update addressing environmental concerns/AIP Funding and economic stimulus package, and a closing session on National Fire Protection Association (NFPA) 409: Standard on Aircraft Hangars. Summit to Address Regulatory and Business Issues Unique to the Part 135 Community

NATA Safety 1st eToolkit – Issue 51 – April 17, 2009 Page 16

NATA Safety 1st eToolkitNATA Safety 1st eToolkitChief pilots, directors and company executives of Part 135 operations are invited to receive an exclusive FAA regulatory briefing by the agency's highest-ranking officials. The Summit's agenda also includes sessions on certificate revocation, your rights in responding to enforcement actions, balancing your budget without compromising safety and compliance, the latest developments on the TSA's Large Aircraft Security Program, a panel on the future of general aviation manufacturing, and rebutting the public and media blitz against business aviation. Back to Back This Year These events will be held back to back this year at the Westfields Marriott in Dulles, Virginia, to allow aviation business leaders to connect with their colleagues, customers and business associates. The Air Charter Summit (June 8-10) was designed exclusively for Part 135 operators and the FBO Leadership Conference (June 9-11) for executives and managers of fixed base operations, but those who have an interest in both will want to stay from June 8-11 to achieve maximum productivity. Visit www.nata.aero/acs or www.nata.aero/fbolc for more details and to register for one or both events. Attendees Sound Off About NEW LSST NATA held its third Line Service Supervisor Training Seminar at Education Week in Las Vegas. The following comments regarding the new seminar format and speakers were shared by participants in a closing survey: “All of the topics discussed are real life occurrences, not hypothetical.” “The speakers covered significant information that I use every day in the workplace. I will definitely send more of my employees to this training.” “Dr. Mario Martinez got the group involved and thus developed and maintained everyone’s interest in the seminar. He did an excellent presentation of the materials.”

“Dr. Dewett is a great speaker. You can tell he is passionate about his work He really made the topics understandable by relating personal stories to drive the messages home.” “Some motivational speakers are not motivational at all. Dr. Dewett was an exceptional motivator. His whole presentation was relevant and brought many memories. The subject matter examples were very similar to my own.” “All of the LSST topics were amazing. I wish there could have been more time.” “This is the fourth time that I have been to this seminar and it was interesting and different each time.” “I had heard of Walter Chartrand, so I had expectations. I was not disappointed. Walter was knowledgeable and funny” “Mr. Chartrand was an excellent speaker. His knowledge of customer service is remarkable.” “Adam rocks. I felt the seminar was set up very well, moved at a great pace and was not boring. I would attend this training annually or biannually.” “The seminar was lively and informative, even on topics that could be dull or mundane. Adam was great!” “This seminar exceeded my expectations. I received detailed information while being able to interact with others in similar situations. The JetParty exercise contained a lot of information that was reflective upon what we had learned.” The next LSST will be held May 12-13 in Windsor Locks along with the How to Build a More Successful FBO Seminar and the final Environmental Compliance Seminar for 2009. Come see and hear what they are talking about. The full 2009 seminar schedule can be found by clicking on the events calendar at www.nata.aero.

NATA Safety 1st eToolkit – Issue 51 – April 17, 2009 Page 17

NATA Safety 1st eToolkitNATA Safety 1st eToolkitCONTINUING EDUCATION General Education Offerings Coming in 2009 Environmental Compliance May 11, 2009 in Windsor Locks, CT http://www.nata.aero/Event.aspx?page=1248&sectionid=553 Line Service Supervisor Training Seminar May 12/13, 2009 in Windsor Locks, CT http://www.nata.aero/Event.aspx?page=1228&sectionid=553

How to Build a More Successful FBO May 14-15, 2009 in Windsor Locks, CT http://www.nata.aero/Event.aspx?page=1250&sectionid=553

Air Charter Summit June 8-10, 2009 in Washington, DC (Dulles) http://www.nata.aero/Event.aspx?page=1259&sectionid=553 FBO Leadership Conference June 9-11, 2009 in Washington, DC (Dulles) http://www.nata.aero/Event.aspx?page=1260&sectionid=553 NATA Safety 1st Management System (SMS) Workshop June 23, 2009 Omaha, NE http://www.nata.aero/Event.aspx?page=1262&sectionid=553 Line Service Supervisor Training Seminar June 15-16, 2009 in Clearwater, FL (during FATA) http://www.nata.aero/Event.aspx?page=1232&sectionid=553 Accident Prevention Via Human Factors June 17, 2009 in Clearwater, FL http://www.nata.aero/Event.aspx?page=1256&sectionid=553

Line Service Technician Boot Camp August 19/20, 2009 in Minneapolis, MN http://www.nata.aero/Event.aspx?page=1252&sectionid=553 NATA Safety 1st Management System (SMS) Workshop September 16, 2009 in Windsor Locks, CT http://www.nata.aero/Event.aspx?page=1264&sectionid=553 Advanced Line Service Supervisor Training September 23/24, 2009 in San Diego, CA http://www.nata.aero/Event.aspx?page=1255&sectionid=553 Line Service Supervisor Training Seminar October 23-24, 2009 in Baja, Mexico http://www.nata.aero/Event.aspx?page=1249&sectionid=553 2009 Schedules: Aviation Safety and Security Offerings Embry-Riddle Aeronautical University's Center for Aerospace Safety/Security Education (CASE) Details online: http://www.avsaf.org/programs_events.html Southern California Safety Institute Website: http://www.scsi-inc.com/ The GW Aviation Institute Aviation Safety and Security Certificate Program http://www2.gwu.edu/~aviation/safetyandsecurity/ss_courses.html

Transportation Safety Institute Details online: http://www.tsi.dot.gov/Catalog/Default.aspx?value=DTI-20 University of Southern California Aviation Safety and Security Program Details online: http://vitserbi.usc.edu/aviation/

The National Air Transportation Association (NATA), the voice of aviation business, is committed to raising the standard on ground safety. NATA began with the Safety 1st Professional Line Service Training (PLST) Program in 2000 and expanded with the adoption and implementation of the NATA Safety 1st Management System (SMS) for Ground Operations in 2004. The eToolkit provides continuing education in support of the PLST and SMS programs.

Subscribe to NATA Safety 1st eToolkit. If you are not currently a subscriber to NATA Safety 1st eToolkit and would like to receive it on a regular basis, please mailto:akoranda@nata.aero. The NATA Safety 1st eToolkit is distributed free of charge to NATA member companies and NATA Safety 1st participants.

PARTICIPATION AGREEMENT

NATA Safety 1st Management SYSTEM (SMS) FOR GROUND OPERATIONS

Yes, we want to sign up for the NATA SMS for Ground Operations! We understand the following will be included in the price of our participation in the SMS:

Contact Information (please print legibly)

CEO/Owner Email

Safety Coordinator Email

Company

Street Address

City State Zip

Phone Fax Email

Pricing

-

tions. Please note that we will correspond with one Safety Coordinator per company and will require additional company

information once established in the program. Please check appropriate box below.

� $600 for NATA Safety 1st participants / NATA Members with 0-50 employees

� $1,200 for NATA Safety 1st participants / NATA Members with 51-150 employees

� $1,800 for NATA Safety 1st participants / NATA Members with more than 150 employees

Non-NATA Members please call for pricing. If you are currently an Air Operatons SMS participant, you are eligible for a

25% discount on the Ground Operations SMS.

Payment

� Check enclosed (Please make payable to Aviation Training Institute, LLC.)

� Please charge my � MasterCard � Visa � American Express

Credit card number _________________________________________________________ Expiration _____________________

Signature__________________________________________________Name on card___________________________________

Fax to (703) 845-8176 or mail to NATA Safety 1st SMS, 4226 King Street, Alexandria, VA 22302

Agreement

I understand as CEO/Manager of this facility, safety is a core value. As such, the authority and responsibility to

implement this program is placed with me. I will provide the resources necessary to ensure the safety of our customers,

their equipment, our employees and the environment in our daily operations.

Signed this date___________________________CEO/Owner Signature______________________________________________

4226 King Street / Alexandria, VA 22302 / (703) 845-9000 / Fax: (703) 845-0396

� SMS Guide� SMS Webcast Tutorials � SMS Consultation by Telephone or email

� SMS Secure, Online Event Reporting Form� SMS Monthly Online Newsletter� SMS Root Cause Analysis

FOR IMMEDIATE RELEASE FOR MORE INFORMATION CONTACT

Eric R. Byer

Vice President, Government & Industry Affairs

800-808-6282

ebyer@nata.aero

NEW NATA LEADERSHIP AND BOARD OF DIRECTORS ANNOUNCED

Alexandria, VA, March 24, 2009 — National Air Transportation Association (NATA)

President James K. Coyne announced that Kurt Sutterer, president, Midcoast Aviation, Inc.,

recently assumed the chairmanship of the association replacing Dennis Keith, president, Jet

Solutions, LLC. Sutterer became chairman of the association during the last NATA Board of

Directors meeting on March 11, 2009.

Sutterer was appointed president of Jet Aviation’s new maintenance and

completions organization in North America in March 2006, when

Midcoast Aviation was acquired by the Jet Aviation Group.

He joined Midcoast Aviation in 1981 and has served as the company’s

president since November 2004. Sutterer started his career at the St.

Louis-based maintenance and completions company and held various

positions of increasing responsibility, ranging from inspector to manager

of technical services to vice president and general manager of Midcoast Aviation operations

before his promotion to president.

He is a Graduate of Linn State Technical College and a licensed A&P mechanic.

For more information on Kurt Sutterer and Midcoast Aviation, please click here.

The association also named its new vice-chairman, James Miller, executive

vice president from Flight Options. Miller oversees the management of the

Flight Options fleet, Aircraft Management, Whole Aircraft Sales &

Acquisitions, and Aircraft Completion & Refurbishment.

Miller started his career as an engineer and programmer with IBM

Federal Systems Division, having responsibilities for various avionics

and ship-board systems design and development efforts. In 1968, he

founded Miller Aviation and later Miller Avionics and Miller Information

Technologies, serving as their president and CEO.

To view Miller’s complete bio, please click here.

“The last 12 months have been an incredibly volatile time for the general aviation industry,”

stated NATA’s Coyne. “We were extremely fortunate to have had Dennis Keith as our chairman

to help us navigate through these rocky waters. We now look forward to having Kurt, with Jim

as our vice chairman, do the same as the general aviation industry looks to rebound from a

dismal 2008.”

In addition to announcing the new leadership, the association also elected three new members to

its board of directors. Those three new members include Todd Duncan, chairman, Duncan

Aviation, Kenneth Forester, CEO, Meridian Air Charter and Mark Willey, CEO, Bridgeford

Flying Services.

Todd Duncan has a life-long association with Duncan Aviation, and has

worked at the company since 1989 when he started in Aircraft Sales.

Since then, he has served the company in various capacities, most

notably as president of the Component Services department and as vice-

chairman of Duncan Aviation's Advisory Board. He is currently chairman

of Duncan Aviation.

Duncan began his flying career in 1987, becoming a licensed private

pilot in 1988. He then achieved his Instrument Rating and his Multi-engine rating.

Duncan has served on the board of directors for several local nonprofit organizations,

including Lincoln Children’s Museum, Cornhusker Bank, Nebraska Wesleyan University,

Junior Achievement, Lincoln Chamber of Commerce, Boys and Girls Club of Lincoln and

Lancaster County, NATA’ s Air Charter Safety Foundation, and Southeast Community

College Foundation. He is a member of the Nebraska Chapter of the Young President’s

Organization, and the Aircraft Owners and Pilots Association since 1988.

To learn more about Todd Duncan and Duncan Aviation, please click here.

Kenneth Forester is the CEO of Meridian Teterboro/Meridian Air Charter,

companies with over fifty years of experience in the general aviation industry.

He is currently qualified in the Cessna Citation. His other type ratings include

the Learjet and Gulfstream IV. Forester graduated from the U.S. Air Force

Academy and served in the U.S. Air Force flying the F102.

To learn more about Ken Forester and Meridian Air Charter please click here.

Mark Willey is managing partner of Corporate Airpark, and CEO of

Bridgeford Flying Services and Actus Aviation. Since 2000, he has continued

to develop and improve upon the company's 63-year legacy. Willey has led the

growth of Bridgeford to a world-class FBO, aircraft management, sales and

charter provider and premium quality flight school and repair station.

Prior to Bridgeford, Willey was with the DuPont family-owned Atlantic

Aviation for 17 years, the last 7 as vice president and general manager of

their Wilmington, DE headquarters. He also held leadership positions for a subsidiary of

Consumers Glass, Inc.

Willey’s affiliations include serving in various civic and community organizations and on

various profit and non profit boards including Hospice, SL Surface Technologies Inc. He is a

past member of an Aviation Executive Roundtable and a past member of the NBAA

Business Committee. Willey currently chairs the Business Management Committee for

NATA, and is a member of the Society of Aerospace Engineers. He is on the Napa Chamber

of Commerce Board and the Napa Airport Security Committee, and is a member of the

aviation industry renowned FBO 1 peer group.

To learn more about Mark Willey and Bridgeford Flying Services, please click here.

“We are delighted to have such an outstanding and talented new class of NATA board

members,” Coyne concluded. “It is critical that the NATA Board of Directors guide the

association, ensuring continued economic growth and financial viability while reinforcing that

safety is the highest priority for all of its members. Todd, Ken and Mark clearly recognize these

core values and will guide our association accordingly.”

To view the complete NATA Board of Directors listing, please click here.

# # #

NATA, the voice of aviation business, is the public policy group representing the interests of

aviation businesses before Congress and the federal agencies.