Again, we can learn a lot from RCA’s done in other high risk industries. In 2006 Comair Flight 5191 crashed in Lexington, Kentucky after taking off inadvertently from the wrong runway, which was too short for a commercial airliner (this runway was used by small general aviation planes). All passengers and all but one crew member died in the crash. The NTSB analysis of the crash determined that pilot error was the primary reason for the crash. In particular, they felt that sufficient cues should have been available to the pilots to inform them they were on the wrong runway and that distractions, particularly a nonpertinent conversation between the captain and first officer during the taxi procedure and takeoff, were a primary cause of the crash. Moreover, a leisure-like atmosphere in the cockpit may have been a contributing factor. The concept of a “sterile cockpit”, in which all attention is focused on flight-related factors and no “nonpertinent” conversation is allowed, is applied during taxi and takeoff procedures.
Airlines do Line Operations Safety Audits (LOSA’s) that usually do include looking for “sterile cockpit” violations. But Comair apparently did not have a formal process for assessing for sterile cockpit violations.
The crew also did not cross check and confirm the plane’s position on the runway before takeoff and confirmation bias likely contributed to their thinking they were on the correct runway. Only after they had reached a point at which they could no longer abort the takeoff did they realize they were on the wrong runway.
The lone air traffic controller on duty at the time was engaged in an administrative task (that was of low priority) and did not notice that the plane was on the wrong runway.
NTSB recommendations (pardon some of the technical terms) included:
One NTSB board member added her own comments aside from the formal report and felt that a substantial number of latent errors or conditions were contributory factors. In particular, she noted that there seemed to be no apprehension on the part of the crew in using abbreviated briefing procedures and engaging in nonpertinent conversation during the “sterile cockpit” period. She therefore wondered how abnormal those behaviors were, i.e. whether such behaviors had actually become the norm at this and other airlines. She also pointed out that this particular airline did not include a heading check (to ensure that the heading of the plane was aligned with the anticipated heading of the runway) in its pre-takeoff checklist, something that most other airlines had already incorporated.
Are there analogies to this case in healthcare facilities? Certainly sounds a lot like the sort of issues that led to development of the surgical timeout. The “sterile cockpit” concept also applies to the surgical timeout/final verification process. It also applies in those central pharmacies where the pharmacist is expected to do certain work without interruptions. And one could make a case that it should apply to any healthcare worker tasked with doing a double check or second “independent” verification (eg. for a blood product or a chemotherapy infusion rate). There are probably many other circumstances where the “sterile cockpit” concept applies.
How many healthcare organizations actually audit or monitor those processes to see how often the “sterile cockpit” process is indeed “sterile”? We recommend that periodic audits of at least the surgical timeout be done via a sampling methodology.
Of interest, the NTSB report mentioned that a LOSA Collaborative showed that flight crewmembers who intentionally deviated from standard operating procedures were three times more likely to commit other types of errors, mismanage more errors, and find themselves in more undesired aircraft situations compared with those flight crewmembers who did not intentionally deviate from procedures. We suspect the numbers in healthcare would be similar. So auditing as above might identify risk for other situations.
Certainly, there are lots of lessons to be learned from this aviation safety root cause analysis. However, one cannot help but wonder that they left out the most significant solution. The best fixes in any RCA are forcing functions or ones that prevent someone from doing by accident something that will have dire consequences. In healthcare, we use special connectors that prevent oxygen lines from being hooked up to nitrogen lines, or connectors that prevent a feeding tube from being hooked up to an IV line. We also remove the vials of concentrated KCl from floor stock so it cannot be inadvertently administered in fatal dosage. Even if fully barricading the entrance to that short runway is not feasible, I’ll bet healthcare safety personnel could easily come up with at least a dozen ways to make it physically impossible for a big airplane to get on a runway intended only for small airplanes. Just like healthcare inviting experts from other industries to help do RCA’s in healthcare, maybe the airline industry needs to invite patient safety experts to help in their RCA’s!