The May 13 May 14 issues of The Wall Street Journal ran multiple stories about the current NTSB investigations into the tragic February 2009 Colgan Air crash in Buffalo. While the agency has not yet ruled on the cause of the accident, there's been a lot of testimony and documentation focusing on the role of pilot training, pilot error, and the interactions between crew members that prevented correction of what a senior test pilot for the airplane manufacturer termed a "recoverable stall." In medical safety terms, "a near miss."
So it should be no surprise that I found these articles both riveting and highly connected to the dilemma of health care leaders charged with safeguarding patient safety. Since airline safety practices, especially crew resource management (CRM), are seen as models for medical error reduction, the failure of airline safety practices should teach us something important. These articles are rich and provocative so I'll hit on just a few points and leave it to you to read them and more fully relate them to health care.
There's Always More Than One Error
Doomed Pilots Talked of Inexperience, one of the two investigative pieces by the Journal's Andy Pasztor, chronicled the flight's final cockpit conversations which included chatter about the pilots' personal lives as well as a haunting repartee about their combined inexperience in the type of icing conditions that evolved minutes before the crash. The snapshot of multiple shortcomings is troubling on a number of levels worth connecting to medical safety - which also teaches us that it takes multiple sequential risks or errors to result in an actual adverse outcome.
Risk 1 - A Culture of Ignore-ance
The FAA prohibits "idle chatter" in the cockpit during landing approaches. At this time, the pilots are supposed to be focusing on the complexities of safely landing the plane. An FAA safety inspector was quoted as having commented on how the carrier ignored this rule:
"At Colgan, even with the FAA aboard," he told the board, pilots engaged improperly in conversations. Describing the problem as systemic, [he] said it was a part of culture that indicated "you can kind of slide by, cut corners, wink and nod when the FAA is not there."
This aspect of the crash slip had nothing to do with training, readiness, or competency. It was about a culture that did not respect well founded rules - and the resulting lack of focus that turned landing the plane from a dangerous and complex act into a "routine" procedure. By chattering instead of discussing scenarios in which the accumulating ice might affect flight performance, and how to manage them, the pilots wasted valuable time.
Is this experience relevant to the idle chatter that takes place in the operating room during complex procedures? How many times have I observed surgeons performing complex and risky procedures while discussing trivialities? How many hospital rules, "best practice" recommendations, and regulatory guidelines are routinely flouted due to a culture that values professional prerogatives over compliance and consistency with evidence based practice? While any breach alone may not cause an adverse event, several can get you there.
Risk 2 - Trained? Ready?
The Colgan pilots were trained - didactically. But the training itself was potentially insufficient or incompletely documented: "[The captain's] records showed discrepancies about the dates he passed or flunked certain tests, which Colgan attributed to clerical error." And the cockpit team was far from experienced and ready for the conditions they faced. The copilot: "...was hired by Colgan less than a year earlier and had done most of her training in the Southwestern U.S."
So notwithstanding the fact that they frittered away precious minutes (Risk 1) "...the crew didn't discuss a plan in case of emergency, instead trading personal anecdotes..." they were dispatched to do a job for which they simply had an insufficient combination of training and experiential exposure. And therefore they didn't have the right knowledge base or instincts to call upon when split second decisions were required.
Can we say that as health care professionals in training and practice, we are not regularly called upon to do things for which we have less combined education and experience than we should? Recent shifts in medical education that require better tracking of specific educational and procedural experience are a move in the right direction. But as the airline experience shows, the requirement alone may not be sufficient to ensure each professional is actually competent in every area of practice required to ensure safety:
"The hearing also revealed Colgan previously failed to maintain detailed records of pilots who failed proficiency tests, or track their progress as they tried to pass flight tests. Colgan witnesses said that about 5% of its pilots fail flight tests annually, and about six of Colgan's roughly 500 pilots have failed more than one such test."
How much tolerance do we in health care have for professionals who have demonstrated less than 100% competency breadth - and what are the ramifications of the shortfall? Do we circle back to be sure everything essential has been mastered or do we slip through most of the time by beating the odds?
Risk 3 - Safety Reporting and Consumer Choice
In Regional Routes Served by Big Carriers Are Often Operated by 'Feeder' Airlines and Crash Probe Examines Pilot Fatigue, both also by Mr. Paszrtor we are reminded that we know little about the differences between airlines or between regional carriers and major airlines: "Don't expect to find an official ranking of airlines by the number or severity of mishaps, though. In the eyes of regulators, airlines are considered safe as long as they are authorized to fly."
Regional carriers have the "look and feel" of the majors: "The flights are branded under the large carrier's name -- or something very similar -- and they often feature the same colors and crew uniforms." But are they the genuine article? "Like many commuter carriers, pay at Colgan was at the bottom rung of the industry." Does that buy the same quality as the majors? Are there similarities to the dilemma of representing and assessing the quality of care delivered by residents or fellows on behalf of highly reputed physicians - or of affiliated hospitals in a system with a high reputation flagship?
And what can you, as a consumer, tell about the factors contributing to either airline or medical safety. In both cases fundamental training and licensing information is available to the public. And in both cases, selected but spotty information about prior misadventures or performance is available on a professional specific basis.
"Information about specific airline pilots is even more difficult to obtain. The FAA Web site features a registry of licensed aviators, but it only compiles data regarding what certifications individual pilots have. While NTSB reports detail specific violations pilots may make if they contribute to any mishap, no public database exists listing all pilot violations or comparing the records of pilots at any given carrier with those of another"
But is this enough for officials or consumers to make informed choices about quality and safety? "Efforts by others to compare airlines by their safety records have also proved difficult. The safety of a particular flight (or medical procedure) depends on myriad factors ranging from aircraft type (diagnostic or therapeutic equipment) and pilot (physician) skill to weather (how busy we are) and airport infrastructure (hospital facilities)."
Despite the push for transparency in reporting, it sounds like the problems of training pilots and of assessing airline safety are similar to those of preparing and comparing doctors, hospitals, or treatments. In the end, it all depends on how multiple complex factors interact on a particular occasion. Reassuring, isn't it.
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