Picture: www.friendshipcircle.org
The year 2014 was arguably the annus horribilis of civil aviation, at least for South East Asia. We had the twin tragedies affecting our national carrier, followed by the shocking accident of another aircraft belonging to a regional one, all of which led to the tragic loss of close to 700 lives, most of who are still unaccounted for.
As such, it’s no surprise that many in the civil aviation industry had attempted to find out why such things still happen in spite of the tremendous advances in safety technologies. In my capacity as an aircraft commander, I was no exception.
In an international aviation conference last week, I presented a paper entitled “CRM Strategies for Pilot Training” which essentially identified the human factor as a key variable in air accidents.
In this article, I wish to share some parallels between flight safety and professional medical practice, which can hopefully foster better understanding of our common safety objectives.
CRM is an acronym for Crew Resource Management, which simply means the use of all available resources to mitigate risks and arrest possible human errors in accident prevention.
In civil aviation, the notion of CRM exists because of three introvertible truths in post-accident analysis.
The first is the fact that all accidents involve some degree of human error. The second is that no accident ever happens from a single event but actually the end result of a series of errors (commonly referred to as an ‘error chain’). Thirdly, every error has the capacity to escalate into a life-threatening event, no matter how miniscule it appears at the beginning.
In essence, both pilots and medical professionals have the same purpose, which is saving lives. It’s shallow to presume that the job of any high-risk transport professional (whether pilots or ambulance drivers) merely entails moving people about from point A to point B – just as it’s naïve to assume that GP doctors are only there to combat flus!
When people ask me what I do for a living, I tell them I’m an airline pilot. But when asked to describe my job, I tell them I am in the “business of saving lives”, plain and simple.
It’s an open secret that airline pilots only spend a fraction of their training on flying the plane itself. The bulk of it is to prepare for emergencies – because many emergencies require us to manage the altitudinal oxygen profile to ensure that our passengers stay alive, especially in rapid decompression situations.
Likewise, the job of a flight attendant is more than just “Coffee, Tea or Me?” as most people think! The actual purpose of having flight attendants is to comply with a global regulatory requirement that all passengers must be evacuated in 90 seconds in the event of a severe contingency following an aborted take-off or baulked landing.
These realities compel the aviation industry to continuously examine its safety processes and protocols involving human factors. Medical professionals would similarly benefit from CRM training to attain the same safety objectives as their partners in civil aviation.
Research on past human factor errors suggests that as far as intent is concerned, there is little distinction between doctors and pilots, nurses and flight attendants, or hospital regulators and air traffic controllers.
The sole difference is the scale of the mistake. It’s commonly said that if a doctor makes a mistake, someone may die but if a pilot makes a mistake, hundreds (or even thousands) may perish.
Yet one thing is certain. Irrespective of the number of injuries or deaths, the principle remains the same. A doctor who misdiagnoses a patient’s medical problem is no different than a pilot who misjudges the severity of an engine failure, since both misinterpreted the information presented to them, which led to the erroneous diagnosis.
CRM ensures that good decisions are made. It recognises that in complex, high-risk endeavours, it is the team (not the individual) that leads to safe outcomes through a team-based practice that uses every available resource to reduce the risk of an error-chain developing.
In the cockpit, pilots rely on CRM to ensure that the co-pilot serves as an effective check-and-balance to ensure that the captain does not continue along a dangerous course of action through an “assertive support process” (ASP), where he is taught to be pro-active whenever safety is being compromised.
The vertical distance between a captain’s authority and his co-pilot is known as the ‘Power Distance’. This is what defines the extent of assertiveness a co-pilot has towards his captain (similar to a junior doctor towards his department head).
In the history of civil aviation, the world’s worst accident happened in 1977 when two Boeing 747s collided on a foggy runway in Tenerife, Spain, leading to a cumulative total of 583 deaths. The cause of the accident was quickly identified: because the captain of the KLM 747 simply decided to take off before clearance was granted, slamming shortly afterwards onto a Pan Am jumbo that hadn’t vacated the runway yet.
While the cause was quickly identified, what was most shocking was the reason it happened: A passive co-pilot who knew that clearance was not given yet decided to keep quiet out of fear towards a senior captain.
High power-distance cultures are common (especially in Asian countries) where juniors are conditioned to revere their seniors, especially the elderly who are perceived to be right all the time.
However, experience from the aviation industry clearly suggests that this is quite often the contrary, as demonstrated by a number of other air accidents aside from the Tenerife tragedy.
In essence, the use of CRM communicative guidelines in the medical field can be derived from cockpit relational dynamics whenever an error-chain is seen to be developing. The “challenge and respond” principle is a good start, as seen in the following sequence.
The first would be to draw attention (e.g. “Attention Capt”), followed by stating the concern (e.g. “We’re 190 knots at 1200 feet”), then the description of severity (e.g. “We don’t have enough fuel”), proposing of solutions (“Let’s divert now”), obtaining of agreement (“check my calculation Capt”), asserting suggestions (“unstabilised, mandatory go-around”) and finally, to acknowledge orders (“your control Capt”).
Additionally, the use of checklists and procedure briefings can also be extended to the medical periphery.
Pilots are often subjected to a long litany of checklists in both normal and non-normal situations. The use of every switch, lever and button from pre- to post-flight is strictly governed by these checklists. While a significant amount of time is required for their correct use in emergencies, it ensures optimum workload during that contingency which helps to minimise the threat of human errors.
Therefore, the possibility of compounding the error remains minimal as the pilots are able to ensure their standard operating procedures by systematic conformity, hence freeing up other resources to manage the problem. After the flight, pilots conduct debriefs to assess the problem (from start to containment) to reconfigure best-practices in the event it occurs again.
The use of the challenge-and-respond method via checklists and briefings may seem like more time is required but it builds error countermeasures. Checklists and briefings help to mitigate risk by identifying, trapping and mitigating an error before it develops further.
Finally, let’s look at the non-punitive reporting system used in most airlines. In this system, both the captain and co-pilot have access to report any safety breach to an independent safety committee to ensure that the breach is immediately addressed by both crew and management to prevent recurrences.
However, such voluntary-reporting systems must be based on non-punitive principles if they were to work effectively. While deliberate violations cannot be tolerated, unintended infringements must not be treated in a similar vein.
Like all fallible human beings, none of us are exempt from making mistakes in the course of discharging our professional duties. Ultimately, voluntary reporting is not about apportioning blame but rather, an assignment of responsibility.
In conclusion, the extension of CRM practices from the airline to the medical profession is apt simply because it entails an input-driven participation whilst providing an avenue for a continuous-improvement process.
The time has come for the Ministry of Health and associated medical bodies to seriously consider CRM training for all staff, from surgeons to anaesthesiologists to nurses and even paramedics, including the use of checklists, pre- and post-treatment procedural briefs.
With such threat and error countermeasures, it is not impossible that medical errors, ranging from wrong-site surgeries to retained foreign bodies may be eradicated in the near future, in addition to a steep reduction in medical malpractice lawsuits.
Capt Dr Thiru Jr is an airline captain with one of the region’s leading airlines. He is a civil engineer by training but quintuples as writer, lecturer, amateur musician, standup comedian and civil activist.This is the personal opinion of the writer and does not necessarily represent the views of The Malaysian Medical Gazette.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]
Respected Sir,
This is indeed a wonderful article extrapolating the possibilities of CRM to the medical profession. While i do agree that many routine errors can be avoided by using a checklist ( ” The Checklist Manifesto ” by Dr. Atul Gawande comes to mind ) I would like to raise a few points about the differences in the two professions. The major one, I should say, is that of “Uncertainty” . True , in the aviation field also there is uncertainty with regard to the weather, timetable, etc… it is unlikely to happen say, a flap lever being pulled and the landing gear goes down…moreover..there is a fixed base of routine things.. like the waypoints entered into the flight management system…in fact to make my point..the whole concept of ” Autopilot ” ” Autoland” results from the number of variables that can remain constant in aviation. Yes, in Medicine , the machines do make easy some of thel work..eg. ventilators or dialysis machines..but the crux is in the “diagnosis”..with the same disease presenting in a myriad ways…the same treatment not being effective in two different patients…hence the fact that clinical experience plays a role. To take the example further, a co-pilot can inform the failure to adhere to standard operating protocol by the captain while landing, take off, etc simply because they are strictly to be followed …but even in the present era of evidence based medicine, where evidence that is statistically proven to benefit a more number of patients( here also, not ALL the patients) there is always a statement saying that theses are guidelines only and the best course of action is to be decided by the treating doctor and there may be two or more therapeutic options leading to the same result. I am yet to see a SOP where flaps 10 and speed at captains discretion is in the QRH.
To make a long story short, CRM, although tried, tested and proven in aviation, has a long way to go with regard to medicine. Thank you for your patience!