Air Canada Almost in Deadliest Accident in Aviation History — CRM Training Saves Countless Lives

sfo near miss aviation simulation

Yesterday in San Francisco (July 10, 2017), Mercury News reporter MATTHIAS GAFNI wrote how Air Canada pilots almost landed an Airbus 320 onto the jetway where four other planes were waiting to take off. The incident provides a strong example of why Crew Resource Management (CRM) communication protocols allowed for everyone involved to create awareness, recommendations, and change. In this case that “must hear” communication helped save almost a thousand lives.

SAN FRANCISCO — In what one aviation expert called a near-miss of what could have been the largest aviation disaster ever, an Air Canada pilot on Friday narrowly avoided a tragic mistake: landing on the San Francisco International Airport taxiway instead of the runway.

Sitting on Taxiway C shortly before midnight were four airplanes full of passengers and fuel awaiting permission to take off, according to the Federal Aviation Administration, which is investigating the “rare” incident. An air traffic controller sent the descending Air Canada Airbus 320 on a “go-around” — an unusual event where pilots must pull up and circle around to try again — before the safe landing, according to the federal agency. FAA investigators are still trying to determine how close the Air Canada aircraft came to landing and potentially crashing into the four aircraft below, but the apparent pilot error already has the aviation industry buzzing.


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“If it is true, what happened probably came close to the greatest aviation disaster in history,” said retired United Airlines Capt. Ross Aimer, CEO of Aero Consulting Experts. He said he’s been contacted by pilots from across the country about the incident. “If you could imagine an Airbus colliding with four passenger aircraft wide bodies, full of fuel and passengers, then you can imagine how horrific this could have been,” he said.

You can bet that this exact scenario conditions will be programmed into simulators around the world, especially for those pilots flying into San Francisco. As well, I am sure that the Ground Control teams at SFO will take a deep look at the lighting patterns for the runway to see what else could be  done to better indicate approaching flights.

In aviation, such near misses cause huge safety investigations from multiple agencies. When does that happen in healthcare for our near misses? — Why is TeamStepps training not mandatory for healthcare professionals like CRM is for aviation industry professionals? Possibly because the lives of the healthcare providers aren’t also on the line, only their patients. Harsh as that may sound, why else would healthcare not force adoption of the issue, like aviation did? Tell us your thoughts in the comments below.

Read the Whole Mercury News Story About the Never-Event here


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WBUR News: In Simulation Era, Your Doc’s First Try At A Procedure Should Not Be On You

training with healthcare simulation

WBUR recently covered the progress and challenges of medical simulation with an interview with SSH Board of Directors members Dr. Charles “Chuck” Pozner:

Most doctors never forget the paralyzing terror of their first invasive procedure.

Dr. Charles Pozner, of Boston’s Brigham and Women’s Hospital, recalls the first time he placed a central line, which involves sticking an eight-inch-long needle into a patient’s jugular vein to place an intravenous line. He had never even seen it done before, but a chief resident offered him the opportunity after a long day working together.

“When I was a medical student, the last thing you wanted to say when someone offered a procedure to you was ‘no.’ You wanted to learn, to be part of the team,” Pozner told me. The chief resident walked him through it without mishap, but “it was an unsafe thing for the patient, and an unsafe thing for me, because I was potentially harming the patient,” he said.

Twenty years later, in 2013, I went through a similar process. I watched a colleague place a central line during my first week as an intern. A couple of days later, I placed my first one, as my senior resident supervised. Thankfully, everything went fine. But that doesn’t mean I’m comfortable with the idea of wielding eight-inch-long needles after only watching someone do a procedure once.

“See one, do one, teach one” is the ancient medical adage for this: that after doctors in training have seen one procedure or operation, they’re qualified to do the next one. It has been the model for teaching physicians for generations.

But in the age of robotic surgery and simulation medicine, is this concept really acceptable anymore? The short answer is no. Clearly, doctors in training should practice on computers and simulated patients, not real ones. Particularly when, according to a study out this week, medical errors are the No. 3 cause of death nationwide.

The longer answer is more complicated. No one openly defends the concept in medical journals — in fact, experts talk about “see one, practice many, do one.” But the “see one, do one, teach one” culture still persists in hospitals around the country, and it remains routine for physicians in training to practice their first procedure on real patients. (As a patient, what can you do about it? See the tips below.)

“Would you fly on an airplane if they say, ‘We’ll drop the price of our tickets but our pilots will opt out of flight simulation?’” – Dr. Antonio Gargiulo

But that is changing, as more hospitals and medical schools invest in high-tech simulation centers like the $12 million center unveiled by Boston Children’s Hospital this week. Dr. Pozner, who is medical director of the Brigham’s STRATUS Center for Medical Simulation, says that in time, medical simulation will mean the death of “see one, do one, teach one.”

The Pilot Analogy

Consider pilots. Chesley “Sully” Sullenberger, the pilot who remarkably landed his plane on the Hudson River, is often mentioned in the medical literature on simulation, as are his hundreds of hours practicing simulated emergencies. If Dr. Atul Gawande famously brought the pilot’s checklist to surgery, simulation proponents think more pilot-style simulation should be brought to medicine. “It’s called procedural memory,” Dr. Pozner said.

And studies show that simulation works in medicine. One small study trained doctors in robotic surgery, showing that they could reach expert level proficiency by the time they operated on their first real patient. “The main advantage of this tool is you can get technically perfect before you even touch a patient,” said Dr. Antonio Gargiulo, medical director of the Center for Robotic Surgery at Brigham and Women’s Hospital.

Read the full Common Health article on WBUR’s website!

World Aviation Training Conference & Showcase Opens in Orlando

wats 2015

HealthySimulation.com is on hand to explore the very successful world of simulation in aviation! This morning at the Rosen Shingle Creek Hotel in Orlando Florida, Halldale Media founder Andy Smith opened the World Aviation Training Conference and Tradeshow (WATS) 2015 to over 1,000 delegates from around the world and more than 80 industry vendors. The event was Diamond Sponsored by CAE, parent company to CAE Healthcare who is one of the leaders in the space.

Michael Whitaker, Deputy Administrator of the Federal Aviation Administration (FAA) provided opened the show with an overview of the most up to date training and certification requirements for pilots, co-pilots, flight attendants and ground crew members. He reminded the audience that the FAA works hard to provide the “Safest most efficient airspace in the world, and your participation in this conference is evidence that your training experiences shares that goal.”

Captain Howard Attarian, Senior Vice President of Flight Operations at United Airlines (UA) followed Mr. Whitaker with an overview of their training program. Some will become regulatory in the future. “UA has a vested interest in staying above safety levels required by regulation to ensure the sage transport of passengers and cargo. Pilots, Flight Attendants, dispatchers, maintenance techs, and airport ops personnel are all included in our training programs.”

A variety of programs utilized by UA include data, flight, assessment, and management, all of which are cross-referenced against upcoming regulations. Statistical information is used to mitigate risk, warning us not to become “data rich but information poor”. Captain Attarian continued “You cannot give lip-service to these efforts – you will need full corporate support of these programs – every department needs to be set up for these programs and reporting needs to be complete. The system must understand mistakes but hold people accountable for their actions. You cannot achieve success without labor by making clear outcomes of how information will be used, promoting a shared model of trust that will enable your programs to succeed.”

When asked “Why United Airlines chooses to put at-risk pilots on notice” Captain Attarian answered “You have to bold, but not brazen. We observed behavior that was unacceptable. We put those responsible on notice. We followed up with a CRM analysis and ride-along program. All of which is supported by rich data analysis which drives the ultimate decision.”

simulation aviation

What’s amazing about being at a WATS conference is to see an entire industry with over 50 years of integrated simulation experience. The value of simulation is never a question, but rather how to continue to tweak the technology and training to ever improve flight safety. While the industry is not without its challenges, being in a space that has fully adopted simulation is a refreshing reminder about what’s to come for Healthcare in the (hopefully) not too distant future.

You can learn more about WATS and the aviation simulation industry by watching my video interviews from the 2013 Orlando event. You can also visit Halldale Media for both their Civil Aviation and Medical Simulation magazines.

Learn more at Halldale Media’s WATS Page


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Challenging Environment Assessment Laboratory

A pioneering research facility is applying aerospace simulation technology to medical research.

The Challenging Environment Assessment Laboratory, run by Toronto Rehab, includes a motion simulator four stories below ground that can recreate different environments, like winter blizzards and bustling streets.

The multimillion-dollar facility was created to test how humans interact with different environments year-round, safely and in a controlled way.

Simulation Lab Toronto

It includes a winter lab, stair lab to understand how and why people fall — a leading cause of injury and hospitalization among seniors. So far, researchers have found that as a person’s hearing starts to decline, their risk of falling increases substantially. They plan to use the lab’s visual and audio inputs to study more about how hearing loss affects balance and fall risk.

BBC Reviews Aviation Simulators

Simulation in Aviation Video

Video games and simulation software designers have for years tried to make players feel like they are really part of the action.

As graphics and sound have improved a greater sense of realism is now possible but beyond the pretty pictures and rumbling soundtrack, how immersed in a virtual version of something can you get?

Marc Cieslak and Richard Taylor went on a quest for the ultimate in immersive simulated experience.

Watch the video at: http://news.bbc.co.uk/2/hi/programmes/click_online/9567040.stm


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What can we learn from Aviation Industry Simulation?

Aviation and Healthcare Simulation

This week I had the privilege of meeting Captain Stephen Wilkinson, co-creator of Medical Management Resources here in Las Vegas.  Stephen was interested in learning more about the Clinical Simulation Center of Las Vegas and I was delighted to chat with him about the similarities between the aviation and healthcare simulation industries.

A great article about Stephen and his work can be found at the Las Vegas Sun website.

Here’s a little snippet:

“When Steve Wilkinson, a retired commercial pilot, and Dr. Steve Montoya, a Las Vegas obstetrician/gynecologist, were neighbors, they realized the similarities between their industries:

• They’re both high-risk and high-stress enterprises where the lives of many are in the hands of a highly trained few.

• They both depend on teamwork and safety to protect passengers or patients.

• They are both complex, meaning success requires proper checklists, protocols and procedures to ensure no details are missed.

• In aviation, the belief was formerly that “the captain is always right” and above being challenged, and error reporting was nonexistent. A similar aura surrounds many physicians, and most hospitals woefully under-report cases of patient harm.”

I feel we have a lot to learn from the aviation industry which has been running communication and skills based learning through simulation for over 30 years now.  And while the situations are different, the resource management and communication tactics are the same.

Have you learned something from the simulation in the aviation industry?  Write to us and share with the community.