A Novel Investigative Approach Helps Operators Chart a Path to a Brighter Future
Introduction
In an industry where safety is paramount, helicopter operators constantly seek ways to protect their teams, passengers, and operations. Traditionally, this focus has involved post-mortem investigations, where a tragic accident prompts rigorous examination to identify failures. But what if helicopter operators could gain similar insights without the tragedy? That’s the promise of a “premortem” exercise—a proactive approach to safety that’s already proving valuable for companies like STAT MedEvac.
The Journey to Prospective Hindsight
For STAT MedEvac, the adoption of premortem exercises was a turning point that began unexpectedly. “Midway through a typical leaders meeting,” Glenn Shields recalled, “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 voiced, ‘Perhaps we are not talking about the right things.’”
Recognizing the significance of this moment, Glenn suggested they try a premortem exercise. Based on Dr. Gary Klein’s work in prospective hindsight, a premortem asks team members to imagine an accident has already happened and work backward to determine what might have led to it. Despite the difficult nature of the conversation, the leadership team agreed that it was necessary. Soon after, STAT MedEvac held a Safety Stand-Down and a companywide premortem exercise.
A Culture of Collaboration and Safety
The premortem approach brings together team members from all areas—pilots, maintenance crews, and administrators—and encourages them to voice their concerns openly. Unlike a post-mortem, which often brings blame, the premortem is a collaborative, blame-free environment. Shields describes it as “harnessing the power of prospective hindsight.” The process allowed STAT MedEvac’s team to discover new risks and recognize strengths, creating a shared sense of purpose in safeguarding each operation.
Delivering the Desired Outcome
During their premortem exercise, STAT MedEvac simulated an accident scene (complete with a realistic-looking overhead shot), producing 734 responses and identifying potential causal factors that continue to inform their safety protocols (see images provided).
Figure 1: STAT MedEvac Premortem Artifacts Shown Clockwise – A simulated accident scene; 734 sample responses generated; potential “accident” causal factors identified and categorized.
Consider Incorporating a Test of the Emergency Response Plan
An added benefit of the premortem exercise is the opportunity to stress-test the company’s ability to respond effectively despite the chaos that inevitably accompanies a tragic accident. We all acknowledge that plans often change in 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. These plans 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 did not activate their ERP during their premortem exercise, Glenn acknowledges that it would have provided an excellent opportunity to test their response without the consequences of plan breakdowns.
Building a Future-Oriented Safety Culture
Engaging in “what if” scenarios allows helicopter operators to uncover insights that can prevent future incidents. By using premortem exercises to adopt a forward-looking mindset, operators like STAT MedEvac are shifting from unfocused reaction to proactive prevention. “The method shows the team that authentic dissent is valued,” Shields said. “It’s a collaborative process that continues to guide our safety efforts and reminds us that every voice matters.”
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 insights needed to ensure 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.”
by Chris Hill
Contributing authors: Glenn Shields and Ronnie New, STAT MedEvac, Pittsburgh, PA
Attribution: Klein, G. (2009). Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making. Cambridge: The MIT Press.