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!
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