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.


Sponsored Advertisement:


“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


Sponsored Advertisement:


Timothy Clapper PhD Articles on TeamSTEPPS Communication Training Opportunities for Medical Simulation Programs

dr timothy clapper

Just received an email from my good friend Timothy Clapper, PhD regarding yet ANOTHER great article he has produced regarding TeamSTEPPS communication practices with regards to healthcare simulation. TeamSTEPPS was developed by the Agency for Healthcare Research and Quality utilizing CRM communication models from the space and aviation industry. Timothy’s work continues to innovate within our community, helping simulation champions better recognize and utilize simulation as a medium for revolutionary change within healthcare.

TeamSTEPPS is a teamwork system designed for health care professionals that is:

  • A powerful solution to improving patient safety within your organization. An evidence-based teamwork system to improve communication and teamwork skills among health care professionals.
  • A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system.
  • Scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles.
  • Developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

TeamSTEPPS provides higher quality, safer patient care by:

  • Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.
  • Increasing team awareness and clarifying team roles and responsibilities.
  • Resolving conflicts and improving information sharing.
  • Eliminating barriers to quality and safety.

Timothy’s Letter and Article Links:

Dear Lance & HealtySimulation.com Readers,

Just an update on my latest article for TeamSTEPPS. You may recall that my first article described TeamSTEPPS and the need for this tool to improve patient safety. I am happy to share that this article is still at #25 on ScienceDirect’s top 25 articles!

This was followed by a second article that outlined some reasons why TeamSTEPPS programs fail and ways to work through those issues. My latest one, just released, focuses on next steps in TeamSTEPPS, including the observation that must be done to assess additional simulation training needs.

Clapper, T. C., & Kong, M. (2012). TeamSTEPPS: The patient safety tool that needs to be implemented. Clinical Simulation in Nursing, 8(8), e367-e373. doi:10.1016/j.ecns.2011.03.002

Clapper, T. C., & Ng, G. M. (2013). Why your TeamSTEPPS program may not be working. Clinical Simulation in Nursing,9(8), e287-e292. doi:10.1016/j.ecns.2012.03.007

Clapper, T. C. (2014, in press). Next steps in TeamSTEPPS®: Creating a just culture with observation and simulation. Simulation & Gaming. doi:10.1177/1046878114543638

Enjoy!

Tim

Timothy C. Clapper, PhD

TeamSTEPPS Master Trainer and American College of Surgeons Advanced Trauma Life Support (ATLS) Educator
Editor, Healthcare Section, Simulation & Gaming (S&G): An International Journal of Theory, Practice and Research
Public Member, Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Anesthesiology
Adjunct Professor & Sr. Instructor, Graduate Instructional Technology Certificate Program University of Colorado at Colorado Springs, College of Education
Dissertation Chair Grand Canyon University, College of Doctoral Studies
Simulation and Education Consultant – TC Curriculum & Instructional Design, LLC

If you are interested in learning about TeamSTEPPS and how it can be used by not only your healthcare staff, but simulation team staff as well, check out the Laerdal sponsored SimGHOSTS 2013 Opening Keynote address provided by Dr. Timothy Clapper, which is permanently available for free on SimGHOSTS.org thanks to Laerdal!

Also, connect with Timothy through his website TC Curriculum & Instructional Design

Help Fund Movie That Connects Aviation Simulation to Healthcare Simulation

aviation team training into healthcare

IndieGoGo, a crowd-funding platform for independent projects, is hosting the opportunity to donate towards: “Beyond the Checklist: A Feature Length Documentary Film”, which explores how lessons from industries like aviation can provide solutions to the crisis of patient deaths and injuries in healthcare. I urge you to join me in pledging towards this important documentary film which will attempt to show how training in the aviation business using evolved communication practices has lead to an incredible safety record, especially in comparison to the number of deaths attributed to medical error now occurring in the United States.

The Concept Behind the Film:

“On January 9, 2009. US Airways Flight 1549 landed in the middle of the frigid Hudson River in New York. Captain Chesley “Sully” Sullenberger and his crew – as well as ferry and Coast Guard crews – had all practiced and trained in teamwork for years. Which is why not a single passenger or crew- member was seriously injured when the plane was totally disabled when struck by a flock of Canada Geese.

Our 60-minute film will demonstrate that healthcare can transform its culture and stem the epidemic of medical errors and injuries in the US and elsewhere. It can do this by learning lessons from the safety model and culture change movement that transformed commercial aviation over the last 30 years and that has been successfully adapted to make other high-risk industries much safer. The film “Beyond the Checklist” shows exactly how this safety model and culture can be implemented in the healthcare industry.

Take a trip on a $14 million dollar flight simulator, and see how pilots, fight attendants, ground crew, and air traffic controllers all learn to work together to make air travel safer. Sit in on training sessions that teach people on very different rungs of the health care hierarchy how to communicate so they can form quick teams and react instantly in crisis. Here, pilots aren’t only graded on how well they guide a plane during both routine flights and crises but on how well they communicate and work as a team with their crew. Flight attendants mechanics, and gate agents and many others learn to speak up when appropriate and challenge each other, as well as the captain and rather than experiencing “push back,” they are thanked for it.

“Crew Resource Management gave you a process and a language…so that if I said to you, captain I’m not comfortable with this, he had to hear that because it was done in a way that we were all trained,” recalls Nancy Burns, who was a flight attendant for 39 years both and experienced the change in culture when aviation introduced CRM. “It meant that if you spoke up they had to listen. It also meant that you had a responsibility to speak up.” Airline personnel are also encouraged to report mistakes – even serious violations – without being punished and all airlines share information about near misses, errors, and other problems to change practice and insure safety.

The film concludes by showing how the lessons of these pioneering practitioners and institutions can be implemented in every single hospital and health care facility so that every patient everywhere is safe. Each and every one of us will someday be a patient. Our lives and the lives of our loved ones depend on whether our caregivers are trained to work together as a team, can learn together to prevent mistakes, and are able to create a culture of safety in healthcare.”

Click here to learn more and donate to the Beyond the Checklist Documentary Film!


Sponsored Advertisement:


Beyond the Checklist: What Else Healthcare Can Learn From Aviation Book Review

suzanne gordon book review

I met Suzanne Gordon, lead author of “Beyond the Checklist: What else Healthcare Can Learn From Healthcare”, at the speaker’s reception of CAE Healthcare’s 2013 HPSN event in San Francisco. At that time, we had a lengthy conversation about the need to reform healthcare communication using proven methods and the opportunity inherent with medical simulation to help to do so.

beyond the checklist book review

Suzanne graciously provided me a copy of her book to review, which I can tell you now is a definite MUST-READ for anyone engaging within any avenue of healthcare, education, and/or simulation. This book goes beyond highlighting key examples of the poor communication practices causing systemic failures within healthcare by also providing a direct roadmap to solve these archaic human-made challenges. The authors poignantly remind us that the status quo of healthcare communication can no longer remain “just the way it is”.

In Beyond the Checklist, Suzanne Gordon:

  1. Diligently lays out the crisis of communication failures occurring within healthcare.
  2. Reminds us of the history of similar communication failures within commercial aviation.
  3. Demonstrates the 30+ year process of research, program development, and training systems implemented within aviation with regards to communication and team-management.
  4. Powerfully explicates “Crew Resource Management” (CRM) as an evolved system for team interactions and operational success.
  5. Highlights successful uses of the initial healthcare version of CRM called TEAMSTEPPS.
  6. Directs our attention to the unavoidable future of healthcare including regulatory bodies and advanced data-capturing systems.

Most incredibly, Suzanne and her co-authors break down the individual components that make up successful team communication, demonstrates how those pieces are failing within healthcare structures, and provides direct examples of how those issues have already been successfully addressed within aviation.

Read some of the excerpts below to better understand the benefits of this work:

“In medicine it seems now to be universally acknowledged that failures of teamwork and communication-not simply failures in technical proficiency-cause the majority of medical errors and injuries in hospitals and other health care facilities. Studies too numerous to cite have documented that it is not the incompetent surgeon or a small group of bad apples in other disciplines that cause harm to patients. It is human factors – the failure of human beings to relate effectively and productively with one another highly technological settings, to recognize human limitations in performance ability owning to “Life factors” such as extreme fatigue and emotional distress, and to actively resist the culture of blame- that are the major cause of patient harm.” p. 8.

“Even when early pilots flew with a navigator, contact was difficult and minimal. From aviation’s inception as a mode of transport, teamwork was rarely a consideration. A large part of pilot training, whether conducted in military, commercial, or general aviation arenas, is often accomplished one-on-one as flight instructors demonstrate and students unquestioningly mimic technical maneuvers-and especially behaviors. The first major milestone in any pilot’s advancement is to fly solo. Until the introduction of CRM in commercial aviation, a pilot’s primary demonstration of competency was based almost entirely on technical aptitude: the ability to perform a standard set of maneuvers and handle emergences (with little or no regard for interaction with the rest of the crew). Although commercial transport pilots flew as crews, competence had little to do with teamwork or error management in the cockpit.” p. 24.

“The aviation safety moment started out precisely because pilots did not accept their human fallibility. Mistaking the end of a very long journey for its beginning, many in medicine do not seem to understand the similarities between attitudes of pilots pre-CRM and those of physicians today. CRM did no succeed because in the 1980s pilots at United and other airlines threw their hands and said, “We give up.” A great many pilots, in fact, dismissed CRM as “Charm school”… to erode their authority. Flight attendants were also initially skeptical. The fact that human fallibility is now universally accepted in aviation is the result of a very long journey that began with a challenge to an ethos that led pilots to believe they had the power of Zeus when, in fact, many only had the hubris of Icarus. The aviation safety movement has worked not only because of the concrete lessons it teaches but also because of the reconceptualization’s ands strategic approaches it has utilized. These have been derived from, and refined through, thirty years of hands-on, human-factors research-in other words, evidence-based changes and developments”. p. 157.

Again, this 261 page book is a MUST READ for anyone engaging in medical simulation today!

Get the softcover version of Beyond the Checklist or the kindle edition through Amazon.com.

Continue reading more great examples of the content available in Suzanne’s book by “Reading More” below.

Read the rest of this entry »