[SPEAKER_03]: Hello and welcome back to AgRAC.
[SPEAKER_03]: I'm Joe Wolpa and I'm really excited to introduce you all today to a new fantastic podcast called the Medical Safety Podcast.
[SPEAKER_03]: I'm going to play their second episode here that goes through three airline disasters at a one of the hosts is a pilot in addition to being a doctor.
[SPEAKER_03]: And they'll tell you what was learned from them and how we can apply that to anesthesiology and medicine in general.
[SPEAKER_03]: The hosts are both family docs in Canada who have done additional training in anesthesiology.
[SPEAKER_03]: It's a unique pathway in Canada that allows anesthesia services to reach areas without doctors who have done an entire anesthesiology residency.
[SPEAKER_03]: The hosts are Adam Shahada and Amir Hamid.
[SPEAKER_03]: Adam is a family-practice anesthetist, lawyer, and professional pilot.
[SPEAKER_03]: He completed his undergraduate medical education at the University of Toronto, followed by his family medicine residency and anesthesia training at Queen's University in Kingston, Ontario.
[SPEAKER_03]: A mirror is a family physician who mostly does anesthesia in a variety of settings from rural to remote.
[SPEAKER_03]: When he's not in the OR, he is either in a small emergency department or covering some of his colleagues in a family medicine clinic.
[SPEAKER_03]: He attended McMaster University in Hamilton, Ontario for his MD, family medicine residency,
[SPEAKER_03]: Overall, the medical safety podcasts will look at how to improve our health care system by integrating human factors into system safety.
[SPEAKER_03]: This starts with improved learning from medical-insidant investigation and eventually proactive safety measures to make the health care system better without waiting for an incident to occur.
[SPEAKER_03]: In the next few episodes, after the one I'm playing for you, they'll look at how medical systems around the world deal with medical errors and incident investigation.
[SPEAKER_03]: After that, they're planning to look at other industries and how they have proactive safety measures before incidents occur.
[SPEAKER_03]: Without further ado, here is their second episode.
[SPEAKER_03]: I highly recommend you find them on Apple Podcasts wherever you get your podcasts and subscribe.
[SPEAKER_03]: We're all going to learn a lot from these guys.
[SPEAKER_02]: This was not an individual fairs, a system failure, there was a fair, human performance navigation, 75% of airline accidents are due to human factors.
[SPEAKER_02]: We don't know the number in medicine is it more like 80% the number is irrelevant, it's a significant number of people that are affected every day of my medical error, and a lot of those are due to human factors, and if in medicine we were to wake up to human factors, we could be saving many lives.
[SPEAKER_01]: Hello, you're listening to the Medical Safety podcast.
[SPEAKER_01]: I'm Amir Hamid.
[SPEAKER_01]: And I'm Adam Shahada.
[SPEAKER_01]: We're physicians in Canada and talking about how to improve our health care system by integrating human factors in system safety, including medical and student investigation, proactive safety measures.
[SPEAKER_01]: In the first episode of the series, we discussed the Elaine Bromley case where a healthy 37-year-old female underwent attempted elective sinus surgery and died after a can't into big can't oxygen to an area.
[SPEAKER_01]: This is where the medical team were unable to establish no way for over 20 minutes and Elaine suffered significant brain damage from lack of oxygen.
[SPEAKER_01]: Her husband, Martin Bromley, a U.K. airline pilot commissioned anonymized and published a report of the circumstances of her death, so that others could learn from it.
[SPEAKER_01]: In particular, he pointed out that human factors rather than any failure of any one person's violin died.
[SPEAKER_01]: As a professional pilot, Martin Bromley knew this was precisely what was happening in the 1970s in aviation.
[SPEAKER_01]: Plains are actually not because of mechanical failures, but because of a failure of human performance.
[SPEAKER_01]: And what we mean by this is not because of incompetence from the pilots, but other factors beyond technical skill.
[SPEAKER_01]: In aviation, he said, human factors are widely taught in using the analysis of aviation accents, or at least they have been for the past several decades.
[SPEAKER_01]: However, they're given cursory examinations in medicine if they're even discussed at all.
[SPEAKER_01]: In this episode, we hope to look at some well-known aviation accents that parallel alone in broadened these cases.
[SPEAKER_02]: So here's where we're going.
[SPEAKER_02]: We're going to recap the alien-brownly case, what happened, and briefly what the findings were, and some of the human factors that were involved.
[SPEAKER_02]: If you want something that's more in depth, you can look at our inaugural episode, which is the previous one.
[SPEAKER_02]: After that, we're going to provide a brief overview of how aviation accidents are investigated in North America, and then we'll discuss three well-known aviation accidents that, in my view, parallel the Elaine Bromley case.
[SPEAKER_02]: The first one's going to be the Eastern Airlines Flight 401, and that happened on December 29th of 1972.
[SPEAKER_02]: The second case is United Airlines Flight 173, which was JFK to Portland, and that crashed on December 28th of 1978, which was six years almost to the day from the previous case.
[SPEAKER_02]: That was a DC-8, and that one suffered a fuel exhaustion while it was troubleshooting a landing gear problem.
[SPEAKER_02]: Finally, we'll look at Air Florida Flight 90, which crashed on January 13th of 1982.
[SPEAKER_02]: That was a Boeing 737, and it solved due to icing on departure and crashed into the Potomac River.
[SPEAKER_01]: So Adam, you're trained as a pilot.
[SPEAKER_01]: Why are we opting to look at the Elaine Bromley case and medical issues through loans of aviation?
[SPEAKER_02]: It's a fair question.
[SPEAKER_02]: Aviation and medicine are not exactly the same.
[SPEAKER_02]: That said, I think that we can learn things from where aviation was 50 years ago and where they've gone to now.
[SPEAKER_02]: And I'll let listeners decide for themselves whether or not they think as I do,
[SPEAKER_02]: that some of the things that happen to Elaine Bromely are similar to what happened 50 years ago in some of these crashes.
[SPEAKER_02]: When I heard about the Elaine Bromely case, it just struck me as very similar in terms of how the physicians acted, how the nurses acted.
[SPEAKER_02]: But more importantly, why they acted the way that they did.
[SPEAKER_02]: We look at aviation accidents now very differently.
[SPEAKER_02]: They did 50 years ago.
[SPEAKER_02]: It's not just, well, they didn't follow the checklist or they didn't do what they were supposed to do.
[SPEAKER_02]: It's what are we training them for?
[SPEAKER_02]: Why didn't they?
[SPEAKER_02]: Can we identify
[SPEAKER_02]: why these pilots didn't do what we obviously see in hindsight that they should have done.
[SPEAKER_02]: And then how can we prevent these accidents from occurring?
[SPEAKER_02]: And we seem to have done a better job of that in aviation in large part because we have the investigator at tools, things like cockroach wasricotors, fight data recorders and so on.
[SPEAKER_02]: But also because there is a mindset that is simply different.
[SPEAKER_02]: And I think I mentioned this on the inaugural episode, which is basically when I talk to people in operating rooms and I work in a lot of different operating rooms in Ontario,
[SPEAKER_02]: people may or may not have heard of this case, but if they have, they typically the responses, oh yeah, that was that situation where they ran into a can and debate and auctionates scenario and they didn't do what they were supposed to do.
[SPEAKER_02]: The discussion is not why they didn't do that, and that's actually not really in the report either.
[SPEAKER_02]: There's just this idea that while there were some human factors up, play without really identifying what those human factors were.
[SPEAKER_02]: But very clearly, they say this was essentially a fixation-duced loss of situational awareness.
[SPEAKER_02]: Basically, this is the idea that you lose your situational awareness, you lose your sense of what accurately is going on around you, the time that has passed.
[SPEAKER_02]: Because you are so fixated on fixing one problem in front of you, that you lose the bigger picture.
[SPEAKER_02]: And in that case of Alain Brahmali, as we're going to see in my recap in just a second, the physicians seem to have lost that picture, and the nurses seem to not have lost that picture.
[SPEAKER_02]: And then another component of that was, as we'll see in some of these accidents, the junior team members seem to have an understanding what's going on, try to bring that to the leaders' attention, and those were ignored for a variety of reasons.
[SPEAKER_02]: So, I.C.
[SPEAKER_02]: parallels will leave it to the listeners to see if they see those same parallels, and then we can go from there.
[SPEAKER_01]: I think it's really interesting that you kind of had this innate sense of understanding of why these events happen specifically because of your familiarity with aviation.
[SPEAKER_01]: Why don't you give us a little bit more details about the Elaine Bromley case?
[SPEAKER_02]: Yeah, so people that want the full details, they can check at our first episode there, but very briefly, Elaine Bromley was a healthy 37 year old woman.
[SPEAKER_02]: She was going for elective sinus surgery.
[SPEAKER_02]: She had a very experienced surgical team, including a very experienced anesthesiologist, as well as a head and neck surgeon, because she was having sinus surgery.
[SPEAKER_02]: And then another very experienced anesthesiologist joined as well.
[SPEAKER_02]: And most of the nurses in the room were quite experienced OR nurses as well.
[SPEAKER_02]: On induction of anesthesia, putting the patient to sleep, the anesthesiologist was unable to place an artificial airway, or talking about your antitricial tube, your laryngeal mask, airway, or even just bagging the patient as you might see paramedics provide oxygen to patients that are unconscious.
[SPEAKER_02]: So, in other words, they just couldn't get oxygen to the patient.
[SPEAKER_02]: They tried multiple different methods to establish an airway, but ultimately, Elaine's oxygenation fell to very low levels for well over 20 minutes.
[SPEAKER_02]: The nurses in the operating room were experienced, as I say, and they recognize the emergency for what it was, what we call a can't-interbate, can't oxygenate scenario.
[SPEAKER_02]: And they went and obtained what's called the tracheostomy kit, which is a method of obtaining access to the patient's airway surgically from the front of the neck.
[SPEAKER_02]: They actually brought the kit into the operating room and announced its presence to the physicians, but they got no response from the physicians.
[SPEAKER_02]: About 35 minutes total time from when they started to induce anesthesia, the anesthesiologists were able to provide oxygen to a lane, but at that point she had been without oxygen for over 20 minutes.
[SPEAKER_02]: Wonders then came into the operating room and told the physicians that she had arranged for an ICU bed because of how sick the patient was.
[SPEAKER_02]: and she received looks from the physicians that seemed to say what's wrong you're overreacting.
[SPEAKER_02]: Elaine was allowed to wake up on her own, she was breathing spontaneously, but again without an artificial airway, and she was taken in that state to the recovery room.
[SPEAKER_02]: By that point, unfortunately, she had suffered significant brain damage, and her husband Martin Bromley in consultation with the medical staff, 13 days later, made the decision to remove her from life-sustaining therapy, and she died.
[SPEAKER_02]: She never did wake up.
[SPEAKER_02]: Modern Bromley, as we mentioned, is an airline pilot, and he said to the hospital ministers that he would wait for the report, but was told that there is no such process in medicine.
[SPEAKER_02]: So he commissioned one.
[SPEAKER_02]: He had it anonymized and later published, and the quote that he used in the front of that report that dedication was, so others may learn and many more may live.
[SPEAKER_02]: And that report found that there was a failure of leadership that resulted in a breakdown of communication, and a loss of situation awareness on the part of the physicians.
[SPEAKER_02]: That's the head and neck surgeon and the two anesthesiologists.
[SPEAKER_02]: Notably, the position said that they did not know why they did not obtain front of neck access as they had been trying to do.
[SPEAKER_02]: They knew the procedures they simply didn't know why they'd failed to do that.
[SPEAKER_02]: And the nurses for their part said that they knew what needed to be done, but they were unable to communicate effectively to the physicians.
[SPEAKER_01]: Thanks for the recap, Adam.
[SPEAKER_01]: I find it really interesting that Martin Brawley coming from his aviation perspective brought this unique lens.
[SPEAKER_01]: If you give us a few more details as to what motivated Martin Brawley?
[SPEAKER_02]: I think he said it really well, Amir.
[SPEAKER_02]: He said in his words, this was not an individual failure.
[SPEAKER_02]: It was a system failure that it was a failure of human performance.
[SPEAKER_02]: And he pointed out that an aviation, 75% of airline accidents are due to human factors rather than, for instance, mechanical failure.
[SPEAKER_02]: And as he said, we don't know the number in medicine.
[SPEAKER_02]: Is it 75%.
[SPEAKER_02]: is it more like 80% is it 40% and again as he says the number is irrelevant it's the fact that it's a significant number of people that are affected every day in my medical error and a lot of those are due to human factors regardless of what the number is and if in medicine we were to wake up to human factors we could potentially be saving many lives.
[SPEAKER_01]: As I think about in medicine a lot of our cases that we talk about are oftentimes anecdotal
[SPEAKER_01]: we don't have titles for them except for like dealing broadly and maybe a handful of other cases.
[SPEAKER_01]: But the fact that in aviation you have these specific landmark cases that you can point to in terms of negative outcomes or learning points, I think is very very unique.
[SPEAKER_01]: So we're going to take a small break and when we come back, we'll actually dive into the aviation accidents and draw some parallels there.
[SPEAKER_01]: And we're back.
[SPEAKER_01]: So Adam, you wearing your pilot hat coming from aviation.
[SPEAKER_01]: Why don't you tell us what happens when someone dies in an airplane
[SPEAKER_01]: What kind of investigations are expected?
[SPEAKER_02]: So you'll remember that Martin Brownley said, oh, he'll wait for the report.
[SPEAKER_02]: What he was thinking was that in aviation all around the world, if someone dies because they're on or near an airplane and in Canada, we call the body that investigates the transportation safety board in the United States, they call it a national transportation safety board, but every country is gonna have their own safety board that operates in a very similar way.
[SPEAKER_02]: And their mandate is to investigate as an independent body, an outside in look.
[SPEAKER_02]: And to look at all of the factors, and so they look at, for example, the training and qualifications of the pilots, the training and qualifications of their travel control, anybody else that may have been involved, flight attendants, etc.
[SPEAKER_02]: They look at the aircraft itself, the engines, the manufacturing, what recently went wrong on the Air Pensions of a maintenance point of view in terms of what was broken on the airplane or what might not have been broken.
[SPEAKER_02]: They look at the air traffic system in terms of whether they look at all kinds of things.
[SPEAKER_02]: And then, at the end of all of this, they are trying ultimately to piece together what happened factually.
[SPEAKER_02]: But then also to perform an analysis to determine why did it happen.
[SPEAKER_02]: And then more importantly, how can we try and prevent this in the future?
[SPEAKER_02]: And they then anonymize this, and then they will provide a publicly available report.
[SPEAKER_02]: And they provide not just that report as to what happened and why they believe it happened.
[SPEAKER_02]: They also put recommendations in, which are non-binding.
[SPEAKER_02]: to the various stakeholders and that might be airframe manufacturers, it might be engine manufacturers, it might be flight training, it might be airlines, maintenance operations, air traffic services, it might be the medical community for how they can look into the fitness of pilots a little bit better.
[SPEAKER_02]: And it might also be, for example, the regulator as to what they could provide better rules in terms of fatigue and flight rules and things like that.
[SPEAKER_02]: And so a whole host of people, we don't have anything like that in North America.
[SPEAKER_02]: We have some mechanisms for investigation, like corners, reports, and so on,
[SPEAKER_02]: And yes, sometimes on a rare basis, you might get some recommendations out of those.
[SPEAKER_02]: But it's interesting as to how sporadically those events happen, and certainly not necessarily an independent investigation, certainly not as a routine.
[SPEAKER_02]: And then the other thing that we don't have, for example, are even the tools with which to investigate.
[SPEAKER_02]: So while the technology exists to have black boxes, for example, in operating rooms or ICU or things like that,
[SPEAKER_02]: We don't have those.
[SPEAKER_02]: The operating room doesn't get up and fly around and crash into mountains and so on.
[SPEAKER_02]: So we clearly have the ability to have these recordings and to try and treat these things.
[SPEAKER_02]: But they don't even have the tools to do them.
[SPEAKER_02]: Let alone the actual investigation.
[SPEAKER_02]: And then to take it even a step further, imagine a situation where we have an investigation where at the end of it in our country and Canada, they were to say to the Ministry of Health and the province, you could do these things and you could mandate these things and this is how we could prevent these things.
[SPEAKER_02]: We don't have that.
[SPEAKER_01]: You leave me to a question Adam, when we have these transportation safety boarding Canada, who is it that regulates or mandates?
[SPEAKER_01]: Whose responsibility is it to carry all these black boxes to conduct these investigations?
[SPEAKER_01]: Where does this funding come from?
[SPEAKER_01]: I see these as friction points in medicine, but do you have any knowledge about that?
[SPEAKER_02]: Yeah, I think we'll probably have to take another episode entirely to look at it.
[SPEAKER_02]: But to answer the question briefly, it's written in law.
[SPEAKER_02]: If you're operating in airline, if you're operating certain types of aircraft, you are required to have cockpit voice recorders and flight data recorders.
[SPEAKER_02]: And keep in mind, the technology has evolved.
[SPEAKER_02]: It used to be a 30 minute physical tape.
[SPEAKER_02]: And part of the problem that they ran into in the 70s, 80s and 90s was that,
[SPEAKER_02]: sometimes you need it more than just the 30 minutes that they had on the tape you need to go back farther we used to have physical tape recorders and now we have more solid state and things like that we just have the ability to gather more data so as the technology improved the legal requirements also improved and that's just how it went and so there's an organization called the
[SPEAKER_02]: International Civil Aviation Organization, and if you are a signatory to that which Canada is in many other countries are, it essentially sets the standards for how your runways are going to be marked, what kinds of phraseology you're going to have over the radio, which changes from time to time, kind of standards you have in terms of acts investigation, who has jurisdiction, because sometimes when plant crash in the middle of the ocean, it's a question as to who's actually going to be investigating.
[SPEAKER_02]: and also who has the resources to investigate and then within the country that you're operating, the transportation ministry or board or whoever happens to be will also have commensurate laws that require this to happen and then the ministry itself will ensure that those airlines are following the standards and each airline will have an operating certificate and if they're found to be in violation of the rules and regulations that are put out, they can have those operating certificates revoked and they can no longer operate an airline.
[SPEAKER_01]: It's, I can foresee the logical challenges of implementing this in medicine, like as we all know here, aviation is the for profit business, and so if they need to generate more funds to accommodate these requirements, they're able to do so.
[SPEAKER_01]: In medicine it's very hard.
[SPEAKER_01]: We can't just start charging patients more money for icing, probably keep on in health care system to then buy black bucks or quarters.
[SPEAKER_01]: Our health care system is continuously that, strapped for resources.
[SPEAKER_01]: So it becomes a very interesting proposition when talking about the implementations to where these funds are going to come from.
[SPEAKER_01]: I want to push back on that a little bit.
[SPEAKER_02]: I hear this a lot, and the reality is there are funds to be found depending on what you're doing.
[SPEAKER_02]: What I will say is this, how much we're spending to help heal people from medical error that we may not necessarily have to spend if we were to implement some of these.
[SPEAKER_02]: So that's the first thing.
[SPEAKER_02]: The second thing that I will say is, in any endeavor, but particularly in this kind of safety endeavor, and we see this law and safety, while those things are very expensive and so on.
[SPEAKER_02]: Cost is a factor, and I think you'd be silly to think it wasn't a factor.
[SPEAKER_02]: However, it is not the only factor.
[SPEAKER_02]: And in any safety endeavor, the first thing that we should be asking ourselves is, what should we be doing?
[SPEAKER_02]: And then the real question after that is, how do we pay for it?
[SPEAKER_02]: You can't put the card before the horse.
[SPEAKER_02]: The real question is, should we be doing these things?
[SPEAKER_02]: And then you find a way to pay for it.
[SPEAKER_02]: So for example, can you imagine today if somebody said in anesthesia, we're not going to have pulse oxymeters?
[SPEAKER_02]: That's just a technology that we just can't afford.
[SPEAKER_02]: You would never say that today.
[SPEAKER_01]: Adam, why don't you take us through the first aviation accident, you think it's similar to what I've been telling you broadly.
[SPEAKER_01]: So this is Eastern Airline Flight 401, December 29th, 1972.
[SPEAKER_01]: We'll link in episode two of the Canadian aviation show Mayday.
[SPEAKER_01]: You should be able to access it for free on YouTube in full, so I didn't take it away.
[SPEAKER_02]: So the Lockheed Elton 11 was the first jumbo jet to crash.
[SPEAKER_02]: It was a new aircraft at the time and you'll see that played a bit of a role in what happened here.
[SPEAKER_02]: Essentially, the flight crew were troubleshooting a landing gear indication problem.
[SPEAKER_02]: Most of the aircraft these days have what are called tricycle landing gear that's where you have one of those gear and two main gear.
[SPEAKER_02]: What happened here was that the nose gear indicating light was not illuminating.
[SPEAKER_02]: So normally what happens is you select the landing gear down.
[SPEAKER_02]: The gear takes a certain amount of time to go down.
[SPEAKER_02]: It then gets locked in place so that it obviously won't collapse on landing.
[SPEAKER_02]: and it indicates, with three green lights, one for each of those, the nose wheel and two main wheels, that it is down and locked, and the nose line in this case was just not illuminating.
[SPEAKER_02]: This is not an uncommon problem, it are a checklist for this, and we can figure these things out, but it takes a little bit of time.
[SPEAKER_02]: And so what was happening was, this was an aircraft that happened to be over the Everglades at night.
[SPEAKER_02]: So good weather, but dark and at night.
[SPEAKER_02]: and so while troubleshooting this they're in a holding pattern with the autopilot flying and the aircraft entered a gradual and unperceived descent at night over the Unlit Everglades and that was likely due to the control column being bumped and it disconnected the autopilot's hold without anyone noticing.
[SPEAKER_02]: and then as they were trying to recycle the land and gear, troubleshoot the land and gear, replace the indicator light, and then that replacement of that and the kind of light went awry where that the light lens assembly jammed.
[SPEAKER_02]: But at the end of the day, there is a physical way that you can actually see if the land and gear is down.
[SPEAKER_02]: And in this case, at a flight engineer has to go down to the sort of the bowels of the aircraft into what was colloquial, a called the hellhole.
[SPEAKER_02]: And he comes back up and he says he can't see the physical indication that would tell whether or not the landing gear was down a locked or not.
[SPEAKER_02]: And that's because the captain had forgotten to turn on the wheelwell lights to allow him to see that.
[SPEAKER_02]: And that's because the Altenalema was a new aircraft and they hadn't had to do this yet.
[SPEAKER_02]: And so in the aftermath of the crash, unfortunately, it was confirmed that it was simply an indicating light problem that the gear wasn't in fact down a locked and only a piece of equipment on the aircraft that defailed was a 12-0 light bulb.
[SPEAKER_02]: The autopilot was thought to have been flying the airplane.
[SPEAKER_02]: There was an uncommended descent that was unperceived.
[SPEAKER_02]: It was over unlet terrain and the aircraft crashed into the Florida Everglades.
[SPEAKER_02]: And no one was monitoring the flight instruments for the final four minutes until a few seconds before impact.
[SPEAKER_02]: And the aircraft crashed.
[SPEAKER_01]: Adam, you're a pilot.
[SPEAKER_01]: Can you tell us a little bit about the logistics in the cockpit?
[SPEAKER_01]: How many people are there?
[SPEAKER_01]: Pain a little bit more of a picture for us.
[SPEAKER_01]: So we understand how challenging this was.
[SPEAKER_02]: This was 50 years ago, and things have changed a lot since then, but to set the scene, it's a new aircraft, and so while the crew is trained on it, they don't have thousands of hours in these airplanes, and so you have a captain who's sitting in the left seat, the first officer who's sitting in the right seat, and then a flight engineer, this was at a time when you often had three pilots in the cockpit.
[SPEAKER_02]: But they actually had to go the flight engineer had to physically go down a ladder essentially into the avionics bay into an area See in a dark essentially hole and the lights weren't appropriately on so they actually couldn't see the indicator And the HR controller actually tried to inform the crew that they were descending and they said Eastern Airlines 401 How are things coming along out there?
[SPEAKER_02]: He attempted to indicate to them that they were descending, but he wasn't specific enough
[SPEAKER_02]: And that's because at the time Radar was far less reliable than it is now, and he saw that there was indication that the aircraft may be lower than it was actually cleared to be.
[SPEAKER_02]: But at that time, it wasn't unusual for radars to be erroneous and then correct itself after several radar sweeps.
[SPEAKER_02]: So it actually wasn't part of that air traffic controller's job.
[SPEAKER_02]: It is now, but it wasn't part of their job at the time.
[SPEAKER_02]: This air traffic controller was quite diligent, tried to actually inform the crew, but it wasn't specific enough.
[SPEAKER_02]: He didn't say that, oh, you're lower than you were clear to be.
[SPEAKER_02]: It's important to note that this is a busy workload time, both for the flight crew and for that air traffic controller.
[SPEAKER_02]: The air traffic controller had five of the aircraft they were controlling.
[SPEAKER_02]: It was an unusually high workload because they were just controlling another aircraft that had made an emergency landing due to its own landing gear problem and so a very high workload for the controller.
[SPEAKER_02]: and yet that was a still a very proactive air traffic controller and in the cockpit what had happened was the autopilot was flying.
[SPEAKER_02]: Now we don't do that this way anymore and that's one of the big outcomes of this crash was you always have to have someone we now call that person the the pilot flying captain is responsible saying you're flying and I'm going to troubleshoot and I'm going to be the pilot monitoring and you're going to be a pilot flying.
[SPEAKER_02]: But at the time autopods were relied on heavily and so
[SPEAKER_02]: the autopilot was quote unquote flying the airplane now we don't say that we say the pilot flying is using the autopilot but the pilot flying is still the one responsible for flying in responsible for where is this airplane in the sky where are they or what terrain and how higher they and and so on.
[SPEAKER_01]: If I could recap the case, Adam, so you have a larger airplane, three people on the cockpit, but to even send one of the people away to look at the logistics of it, meanwhile the plane is descending.
[SPEAKER_01]: They're so focused on addressing the issue with the landing gear and the light that they even, I shouldn't say they miss a cue, but the air traffic control tower attempts to inform them of the descent.
[SPEAKER_01]: They don't do it very forcefully.
[SPEAKER_01]: People are so focused on troubleshooting this landing gear issue that they end up crashing, despite maybe some cues whether forceful or not.
[SPEAKER_01]: And despite having three experienced people at the home,
[SPEAKER_01]: This is a new airplane, these are not junior pilots, these are people with a lot of experiences, it just happens to be a new piece of equipment.
[SPEAKER_01]: Is that more a resort light, right, correct?
[SPEAKER_02]: Yeah, very much so.
[SPEAKER_02]: And there's a couple of key points that I haven't had a chance to mention you mentioned missing cues and there was one big cue that they missed here that was found on the cockpit voice recorder and so the cockpit voice recorder has a number of different microphones one of them is just an area microphone and on that they actually heard the alert that the autopilot gives when the aircraft has descended 250 feet lower than it was assigned to.
[SPEAKER_02]: and what surprised the investigators was, they heard this on the cockpit voice recorder, and it was loud enough that all of the all three pilots could have heard it, however, no one attended to it, no one appears to have heard it, it just seems to have not been perceived.
[SPEAKER_02]: And so that is one of the key pieces that they missed, and why did they miss it?
[SPEAKER_02]: They later found out it's because they were so focused on this problem.
[SPEAKER_02]: So just to delve a little bit more into the mechanics of how they were flying, the apt and could not reach the landing gear light assembly.
[SPEAKER_02]: In other words, these three green lights are on the panel in front of the pilots, but it's closer to the first officer.
[SPEAKER_02]: And that was the person who was also supposed to be flying the airplane.
[SPEAKER_02]: And this person then had dual duties.
[SPEAKER_02]: They were supposed to be flying the airplane, but really the autopilot was flying the airplane, and then that person was then trying to change out the landing light assembly.
[SPEAKER_02]: And so they were so focused on replacing this light bulb that they didn't actually hear this tone.
[SPEAKER_02]: And that was one of the big findings here.
[SPEAKER_02]: And in my mind, this is very similar to the first time the nurse comes in for a lane Brahmalice case.
[SPEAKER_02]: And says, I've brought the trick kid in.
[SPEAKER_02]: I brought the kid for front of neck access.
[SPEAKER_02]: And there is no response.
[SPEAKER_02]: In my mind, those two are quite parallel.
[SPEAKER_02]: You have this altitude alert chime that could have saved everyone's lives.
[SPEAKER_02]: and it just is not attended to it.
[SPEAKER_02]: It appears not to have been perceived by the pilots because of this fixation.
[SPEAKER_01]: Adam, what are the take-home points?
[SPEAKER_01]: What are the kind of conclusions from the investigation?
[SPEAKER_02]: So this was a quite big surprise.
[SPEAKER_02]: It was the very first jumbo jet to ever crash, and as you say, it was an experience crew.
[SPEAKER_02]: And
[SPEAKER_02]: The landing gear problem, even if that nose gear had not been secured, it would not have resulted in nearly the amount of death that had happened with a full-scale crash like this.
[SPEAKER_02]: The landing gear collapsing, you might have some injuries on the evacuation, so twisted ankles, and things like that, however, it became a much, much bigger problem, and so what they found was in trying to
[SPEAKER_02]: Chopper shoot this problem.
[SPEAKER_02]: The crew as a crew, but also the captain as the leader lost situation awareness.
[SPEAKER_02]: And so what they found was this was almost a perfectly functioning airplane.
[SPEAKER_02]: The only thing that failed on this airplane was that 12-dollar light bulb.
[SPEAKER_02]: And as a result of a 12-year light bulb, we have all this death.
[SPEAKER_02]: And so that's when we really started to focus on the idea of how are the crew working together.
[SPEAKER_02]: And this was one of those major landmark cases where we started
[SPEAKER_02]: How do crews respond to the major emergencies like engine failure, engine fire, things like that, which they had obviously been going through in terms of simulators and so on.
[SPEAKER_02]: But how do the crew work together?
[SPEAKER_02]: And how do we have this accident with lots of loss of life from a total of lightbulb failing?
[SPEAKER_02]: And we'll see that
[SPEAKER_02]: This is not the first or the only time that this is going to happen.
[SPEAKER_02]: We've had other situations in other industries, but also in aviation, where a very small, almost insignificant failure leads to this fixation-duce loss of situation awareness with loss of life.
[SPEAKER_02]: And so this brought rise to what they initially called cockpit resource management, that we later call blue resource management, and what we tried to bring into medicine as crisis resource management.
[SPEAKER_01]: You mentioned before that there are common allies between this case and that of lame bromley.
[SPEAKER_01]: You alluded to the nurse bringing in the trait kit you alluded to kind of fixation on the task at hand.
[SPEAKER_01]: Is there anything else that you think really common trends are common themes that that really send out to about these cases?
[SPEAKER_02]: In my mind, there's the failure of leadership and communication which led to a loss of situation awareness in both the Elaine Bromley case and this one.
[SPEAKER_02]: We see that they're both fixation and doose loss of situational awareness, and that it was so acute that fixation led to a lack of perception of precisely the alerts that could have prevented the accident.
[SPEAKER_02]: In the case of the airliner, the altitude alert.
[SPEAKER_02]: In the case of Elaine Bromley, the nurse coming in and saying, we have this trait kit.
[SPEAKER_02]: And we see that there were attempts made, either by the air traffic controller or the nurses and so on, to alert the leaders to what could have saved the day here, but that stimulus while present was not perceived or not acted upon.
[SPEAKER_02]: Overall, we see a failure of leadership.
[SPEAKER_02]: It also in the failure to delegate tasks.
[SPEAKER_02]: And so a failure of the physicians, in particular, the lead in East-Southis, to delegate the intubation or error of manager and to one of his colleagues so that he could see the overall picture.
[SPEAKER_02]: And there's lots of reasons for that.
[SPEAKER_02]: Even I have both been in his situations.
[SPEAKER_02]: You feel quite responsible.
[SPEAKER_02]: You are the expert in airway and so on.
[SPEAKER_02]: It's your patient.
[SPEAKER_02]: We see lots of reasons for it.
[SPEAKER_02]: This is not to find fault or blame or anything like that.
[SPEAKER_02]: It's simply to say that was what had happened.
[SPEAKER_02]: A failure of leadership in the airliner to delegate specifically to flying tasks as opposed to the replacement of the landing gear.
[SPEAKER_02]: Very similar to what we saw in terms of the fixation on intubation.
[SPEAKER_02]: by the lead in Eastist, for example, that failure and delegation was one of the factors.
[SPEAKER_02]: And we see this, we saw, we call this time dilation in the case of Elaine Bromley, which is one effect.
[SPEAKER_02]: We see this also, we can group this together when we talk later on with an airline captain.
[SPEAKER_02]: We'll talk about terms like tasks, saturation, but it's this idea that your workload is so high that some tasks start to fall off, and one of those tasks might be maintaining your appropriate situation loneliness.
[SPEAKER_01]: Thank you.
[SPEAKER_01]: Really cool insight.
[SPEAKER_01]: What I found was also quite interesting about the process of investigation in the context of aviation.
[SPEAKER_01]: As they don't just stop it, what do we think is likely to happen?
[SPEAKER_01]: They actually dig into all the details behind.
[SPEAKER_01]: They do the thing in trauma literature that I see, like the most commonly introduced the second one.
[SPEAKER_01]: So they've obviously identified an initial large thing and now they're looking for other details that could be significant.
[SPEAKER_01]: Adam, is there anything else that the investigation revealed beyond just the initial cause?
[SPEAKER_01]: Is there anything that could have been a contributing factor?
[SPEAKER_01]: or mitigated increased whatever had some sort of impact on this accident.
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[SPEAKER_03]: All right, and now back to the Medical Safety Podcast.
[SPEAKER_02]: I just want to hit on something you just said, Mayor, I think it was a really important point, which is it appears to me in aviation that they really take the responsibility
[SPEAKER_02]: quite seriously where they're not satisfied with just finding the proximate cause of this particular accident, they'll say, well, while we're at it, let's look at the other thing.
[SPEAKER_02]: So for example, we'll see a aviation accidents later on where the main or proximate cause of the accident might have been loss of situation awareness.
[SPEAKER_02]: That might be why that aircraft crashed, but they'll also look at survivability aspects.
[SPEAKER_02]: In other words, they'll say, well, the material caught on fire could make the material better.
[SPEAKER_02]: You'll remember that when you're landing, the flight attendants will ask you to put your tray table in the
[SPEAKER_02]: That's because at some point we realize that if you need to evacuate the aircraft because it crash on landing, those are the features that will allow you to actually get out of your seat, get into the aisle, and actually see whether or not there is a fire or something that is going on, which way are we going to exit and so on.
[SPEAKER_02]: That's all survivability.
[SPEAKER_02]: Those obviously are not the reasons that the aircraft crash, but it does improve the survivability.
[SPEAKER_02]: And so I really want to emphasize the point that you made, which is that it seems like an aviation
[SPEAKER_02]: that they really take this as an opportunity in every manner to how can we make the aviation systems safer even if that wasn't the reason this airplane crashed.
[SPEAKER_02]: And so I found a couple of things interesting in this particular crash of Eastern Airlines 401.
[SPEAKER_02]: One was that during the captain's autopsy it was found that he had a small man in geoma that could have been slow growing in such an area of the brain.
[SPEAKER_02]: This is just a small growth in the brain, non-cancerous, that it could have been such that well maybe it was pressing on the part of the brain that was
[SPEAKER_02]: responsible for vision and maybe it was so slow growing that the captain may not have noticed it wouldn't have necessarily caused symptoms, it wouldn't have necessarily caused headaches.
[SPEAKER_02]: He might have just slowly adapted to it as our brains actually often do, which raised the question of this subtle incapacitation of the captain.
[SPEAKER_02]: Maybe he just
[SPEAKER_02]: couldn't see the altitude indicator, and therefore couldn't see that they were about to crash.
[SPEAKER_02]: Ultimately, the NTSB did rule that out, and it was not a causal factor, but they went to a lot of effort to determine this.
[SPEAKER_02]: The other medical side note was this aircraft crashed into a swamp,
[SPEAKER_02]: The swamp absorbed a lot of the impact and allowed people to survive the initial crash.
[SPEAKER_02]: The mud prevented some people from bleeding out.
[SPEAKER_02]: However, the mud was also a significant source of infection of what's called gaskang green or a claustrudeal mionocrosis, which is just not something that we see very often, and it required eight passengers to undergo treatment and a hyperbaric chamber.
[SPEAKER_02]: Again, not something that I've ever seen from the medical side of things.
[SPEAKER_02]: I just thought it was an interesting side, no.
[SPEAKER_01]: Totally, it's very fun to actually be a medical professional, like the non-medical professional lens on things we do.
[SPEAKER_01]: And I think the striking thing about these tidbits that came out, in addition to the fact that they did a very thorough investigation, is that there's certainly a world where this is the first information found, and the attribute a large degree of cause to this, without actually,
[SPEAKER_01]: putting a critical and scrutinizing lens to this, which I think is the value of having a robust and independent investigation system that isn't necessarily working to find blame or accountability by looking to find areas of improvement and meaningful intervention.
[SPEAKER_02]: It's an ancient point of view because I wonder in medicine, especially when we look at the
[SPEAKER_02]: either unconsciously or because we don't have the same robust medical investigation system.
[SPEAKER_02]: If we don't, as a shorthand, almost do that.
[SPEAKER_02]: Whether it's because we want to protect ourselves and say, well, we now know about this case, this couldn't happen to us or what, it seems like the people that I talked to stop at the, oh, well, they didn't follow the difficult airway algorithm, which as we talked about in the first episode, I only come out the day year before.
[SPEAKER_02]: It seems like,
[SPEAKER_02]: That's the approximate cause.
[SPEAKER_02]: I don't really need to look further into that.
[SPEAKER_02]: When, if we do look further into that, the suggestion appears to be that we are all potentially susceptible to the same human factors that happened that day.
[SPEAKER_02]: And we could all learn to be better clinicians and better leaders and better team managers.
[SPEAKER_02]: And for example, one of the things is,
[SPEAKER_02]: let's identify the new nurses in the room and make sure that they feel empowered to say something because we've all been there at some point where we were the junior member on the team or unfamiliar with the OR and that person may have crucial information and if you don't make it such that they feel like they can speak up they won't speak up and so I think there's a lot to learn from here.
[SPEAKER_02]: I mean someone died.
[SPEAKER_02]: And I think what we all want when that happens can be learned all of the pertinent things.
[SPEAKER_02]: And to me, for putting it short by saying, well, we need to learn the difficult area.
[SPEAKER_02]: I got algorithm and that's it.
[SPEAKER_02]: I think we're leaving things undone that could potentially help us in the future.
[SPEAKER_02]: A hundred percent.
[SPEAKER_01]: We've already spent a fair bit of time talking about this case in particular.
[SPEAKER_01]: And there's still two more to go.
[SPEAKER_01]: So why don't we take a little bit of a break and then we'll come back and try to vote the next one.
[SPEAKER_03]: Stay with us.
[SPEAKER_03]: We'll be right back.
[SPEAKER_01]: All right.
[SPEAKER_01]: And we're back.
[SPEAKER_01]: The second case that you brought to the table item was United Airlines Flight 173, JFK to Portland on December 28, 1978.
[SPEAKER_01]: This is about six years after the initial accident we were talking about, also around Christmas time, also around the holidays.
[SPEAKER_01]: And the main issue here was fuel exhaustion or running out of fuel while troubleshooting a landing gear problem.
[SPEAKER_01]: Again, there is a made a episode about this, we'll link that in our description.
[SPEAKER_01]: Why don't you tell us what happened in this aviation accident?
[SPEAKER_02]: Yeah, so this was a fuel exhaustion which we distinguished from fuel starvation as saying the aircraft literally ran out of fuel like it used all of the fuel up.
[SPEAKER_02]: As fuel starvation sometimes happens when the fuel can't get to the engine.
[SPEAKER_02]: That's not what happened here.
[SPEAKER_02]: This was an aircraft that again, it was a landing gear troubleshooting problem.
[SPEAKER_02]: This time on a DC8 which was an older airplane that was very familiar to all of the people that were flying it.
[SPEAKER_02]: And very similar landing gear problem, while lowering the landing gear, the aircraft experience and abnormal vibration allowed noise and a yaw, which is just a particular type of movement.
[SPEAKER_02]: And again, the landing gear indicator light failed to indicate that the gear was down and locked.
[SPEAKER_02]: This time it was one of the main gears.
[SPEAKER_02]: The crew, which was close to their destination, which was Portland, put the aircraft into a holding pattern near the airport.
[SPEAKER_02]: They circled south of the airport for about an hour.
[SPEAKER_02]: And again, during this time, they tried to troubleshoot the actual landing gear, doing a lot of the things that we had talked about before, recycling the landing gear, changing the light, looking for the actual mechanical indication in the aircraft that would indicate whether or not the gear was down a locked.
[SPEAKER_02]: For fear of the same thing, that if they land with an unsafe landing here, they might have the landing gear collapse partially, and then some people might be injured.
[SPEAKER_02]: Again, this is one of those things where the aircraft ended up crashing because it ran out of fuel, which a lot of people were crashing their heads because if you had to choose between the two, obviously you would choose the unsafe landing gear situation, because as we talked about, that's an eminently survivable situation.
[SPEAKER_02]: and so what ended up happening unfortunately was they circled so long they ran out of fuel and during that time the first officer in the flight engineer tried to tell the captain that the aircraft was low on fuel and that was in part because the aircraft were circling at low altitude and when you're at low altitude the engine is used more fuel that's one reason that aircraft tend to fly higher if they can.
[SPEAKER_02]: The gear was down, meaning it's got more drag and it's burning more fuel, but as the investigation later found out, it wasn't an abnormally large fuel burn that was burning what it would otherwise have been burning, it's just they just held for such a long time.
[SPEAKER_02]: And then 35 minutes after the aircraft entered the holding pattern, the fuel pump lights came on, meaning that the aircraft at that point really should have been heading towards the airport because it's such a low fuel state.
[SPEAKER_02]: The captain says to his crew, well, figure about another 15 minutes, to which the flame engineer says 15 minutes is really going to run a short on fuel here, trying to tell the captain that they are really low on fuel, but again, doing it in a bit of a non-assert of way.
[SPEAKER_02]: The captain in his mind is thinking that he wants to optimize the emergency landing information and preparations.
[SPEAKER_02]: Meaning he wants the flight attendants to be able to get a proper head count, get communication appropriately with emergency ground services.
[SPEAKER_02]: This is via rescue on the ground.
[SPEAKER_02]: and Captain McBrume, who is the captain, again received warnings from his crew that the aircraft was low on fuel, both the first officer and the flight engineer were cutely aware of how serious the situation was, but he ignored them or at least prioritized his concerns and again tried to circle again and the aircraft ran out of fuel.
[SPEAKER_02]: You have to remember that this is a very senior captain and it would have been very difficult in those days to challenge him.
[SPEAKER_02]: The captain is determined
[SPEAKER_02]: He lost sight of the larger emergency, which is the low fuel situation, and again we see a fixation induced loss of situation awareness, trying to troubleshoot that landing gear and running out of fuel.
[SPEAKER_02]: We see that the first officer in flight engineer were ineffective in communicating exactly with the situation once.
[SPEAKER_02]: We see that the aircraft ran out of fuel, and it caused the engines to flame out.
[SPEAKER_02]: Notably, the captain is unaware that the aircraft has run out of fuel until that first engine flame zone.
[SPEAKER_02]: He is surprised and says, why has the engine stopped?
[SPEAKER_02]: He just gets the answer from his crew fuel.
[SPEAKER_02]: The aircraft crashed into a wooded area of Portland about six nautical miles southeast of the airport, the flight engineer and the lead flight attendant were killed, eight passengers, and those two crew members died, and no one on the ground died.
[SPEAKER_01]: And the points that stand out to me about this case are, in addition to maybe not hearing the concerns about the fuel consumption from his colleagues, he also, instead of identifying this is a very salient and significant issue, thought he could defer that decision a to a later time or thought he had more time than he probably had.
[SPEAKER_01]: He was only acutely aware of the issue when one of his engines was lost, where had he recognized his issue earlier, may have had a more controlled, but not ideal landing in an airport where there were already been resources to support him.
[SPEAKER_02]: Is that correct?
[SPEAKER_02]: Yeah, I think you've captured the salient points there, which is that, again, it's an eminently survival situation if you have your gear happen to collapse.
[SPEAKER_02]: And again, we did find out that the gear was actually down in this case.
[SPEAKER_02]: This was just an indicating problem.
[SPEAKER_02]: What it actually ended up happening just for clarification, say, is that the gear had swung down quite forcefully, and the forceful opening of the gear broke a very small micro switch that was supposed to
[SPEAKER_02]: indicate in the cockpit.
[SPEAKER_02]: So again, the gear was down and locked, it was safe to land, just like in Eastern Airlines 401, and so it was a small failure that obviously did not need to bring down the whole aircraft, but that's in fact what ended up happening, and we see similarities between those two cases as well.
[SPEAKER_01]: Any other important findings from the investigation that you can see?
[SPEAKER_02]: So, the NTSB found that the captain's decision to abort that initial landing was prudent because they needed to figure out whether there was a gear problem.
[SPEAKER_02]: It was more the issue, how much time was really spent out there.
[SPEAKER_02]: Are there any perils you can draw between this case and the lembral movies case?
[SPEAKER_02]: So, we see again, a fixation induced loss of situation awareness, and how that can lead to an inability to perceive information, the first officer, and the flight engineer, albeit in a non-assertive way,
[SPEAKER_02]: We're trying to tell the captain that they were low on fuel, but he really should not have been surprised when that first engine flamed out that it flamed out because of a lack of fuel.
[SPEAKER_02]: So clearly, he just could not perceive or adequately integrate that information into his mental model.
[SPEAKER_02]: And then we see that, again, in the nurses situation in terms of a lane problem, where they were trying to tell the physicians that there was a can't intubate can auction
[SPEAKER_01]: I find it also very interesting that in both these cases, you may have had members of the team in the early and broadly case either the winners on the phone ranging for an ICU bed or the one that brought in the Crite Kid versus the flight engineer in the first officer who I take it, do not have as high levels of seniority and may have felt a little bit of a hierarchical pressure not to speak up and advocate for themselves as being contributing factors to this.
[SPEAKER_01]: Any other and tidbits are interesting things that were found either in the investigation or as closing thoughts on this accident.
[SPEAKER_02]: You know, the other day I was listening to a podcast called Ackracker, ACC, RAC, and on there, they were talking about wellness for anesthetists and by the way, if you haven't checked out that podcast, it's amazing and people should check it out.
[SPEAKER_02]: But this was about wellness and one thing that really struck me was what a very experienced academic anesthesiologist had said on that podcast, which was that in her view,
[SPEAKER_02]: anesthesologists tend to have an outsized feeling of responsibility for what happens in the operating room.
[SPEAKER_02]: That may be disproportionately large as compared to what they actually could have achieved in terms of outcomes or what was a reasonable outcome and so on.
[SPEAKER_02]: And I just wanted to point that out as I mentioned to you here that Captain McBroom was held responsible for the accident.
[SPEAKER_02]: He lost his pilot's license.
[SPEAKER_02]: he retired from United Airlines shortly thereafter.
[SPEAKER_02]: He spent his remaining years in failing health conditions, some of which were the result of injuries from the accident.
[SPEAKER_02]: And then friends and family, including some of the crash survivors which did get together on a regular basis after this reported that he was a broken man quote unquote and he was plagued by guilt over his role in the accident.
[SPEAKER_02]: He died on October 9th of 2004 at the age of 77.
[SPEAKER_02]: Meanwhile, what I haven't mentioned to you is that by actively flying the aircraft towards a less built-up area, then the rest of Portland, Captain McBrume actually saved many lives because no one on the ground actually died.
[SPEAKER_02]: The aircraft narrowly missed two apartment buildings, and that we can directly attribute two Captain McBrume, and so while
[SPEAKER_02]: His actions may have resulted in the actual necessity to have this engine outlanding what he did afterwards was save many people's lives.
[SPEAKER_02]: And I point to so because I do talk to a number of physicians who have a lot of guilt over medical incidents and we talk about moral injury and burnout and depression and suicide that plague our profession.
[SPEAKER_02]: I strongly feel that one reason that aviation doesn't necessarily have this problem is their strong acts and investigation system.
[SPEAKER_02]: and I see a lot of physicians that blame themselves and to me as that other anesthesiologists mentioned that we may not necessarily have as much control over the battle comes then within we think we do.
[SPEAKER_02]: I think in aviation, fewer people blame pilots.
[SPEAKER_02]: I say this because in aviation, oftentimes when an airplane crashes, the pilots die and I mean how much more motivation could their beat and saving your life.
[SPEAKER_01]: While I'll set out, you hit on the duality of the personal responsibility of being there when an advertisement occurs versus understanding that there are systems that play that we can't necessarily control.
[SPEAKER_01]: So, as previously alluded to, we have three cases, so we'll take a strike and then we'll be back with the last one.
[SPEAKER_01]: And we're back, this last case is Air Florida Flight 90.
[SPEAKER_01]: This occurred January 13th, 1982, Boeing 737222 stalled due to icing on departure.
[SPEAKER_01]: It crashed into the Potomac with 74 fatalities, including four ground fatalities.
[SPEAKER_01]: There were only four survivors.
[SPEAKER_01]: Again, there's a media episode with this.
[SPEAKER_01]: We'll link it in the description.
[SPEAKER_01]: So Adam, can you tell us a little bit about this accident?
[SPEAKER_02]: So this accident started when they were on the ground and the aircraft had trouble leaving the gate because the tug which usually pushes the aircraft back from the gate was just really icy and the crew tried to use reverse thrust to back away from the gate.
[SPEAKER_02]: Something that Boeing did not advise in that situation in icy situations.
[SPEAKER_02]: Ultimately, what the investigation found was that the pilots failed to switch on the engines internalized protections, despite using a challenge in response to checklists.
[SPEAKER_02]: We're probably going to talk about this in a future episode, but the way checklists are used in large commercial aircraft is one of the pilots reads out what is a challenge in other
[SPEAKER_02]: and that challenge is supposed to have a response by the other pilot.
[SPEAKER_02]: The other pilot actions, the item, or ensures that the item has been actioned as in moves the switch, and then says whatever it is in this case, they said off what they were supposed to do was turn the anti-Is on and say on.
[SPEAKER_02]: So what happened in this case was engine anti ice off and what should have happened was that challenge should have been well, no, it's actually supposed to be on engine anti ice is supposed to be on and that for some reason wasn't actually done appropriately and we think that this is because both of these pilots lived in Florida and did not have a lot of experience in icing conditions and perhaps just not thinking of that.
[SPEAKER_02]: So that was the first thing was that the pilots failed to switch on the engine anti-ice system.
[SPEAKER_02]: They did use that reverse thrust to back out of the gate.
[SPEAKER_02]: Something that Boeing advised against that the may have played a role later on as we'll see.
[SPEAKER_02]: And then on the taxi out, they were in this big lineup to get out as many other aircraft were.
[SPEAKER_02]: And they tried to use the jet exhaust of a preceding aircraft in order to melt off the ice or blow off the snow on their wings.
[SPEAKER_02]: Because the issue is you have ice or snow on your wings that are called contaminated wings.
[SPEAKER_02]: And they really take a very small amount of ice to disrupt a lot of the lift.
[SPEAKER_02]: And obviously if you don't produce enough lift, you don't fly.
[SPEAKER_02]: And so what they tried to do was say, well, I can use the jet exhaust up ahead to try and blow this off, and in fact, it actually exacerbated the situation, it actually made it worse.
[SPEAKER_02]: By doing that, what happened was any snow that was on the leading edge, which is the first part of the wing, it turned that snow into water, which then blew back over the mid part of the wing and then refrow as ice.
[SPEAKER_02]: and they did this because they were 20 aircraft ahead and if they had to go back and get the ice, well, they were going to get even more delayed and they were trying to get home and we'll see in other aviation accidents that they may even duty out.
[SPEAKER_02]: In other words, they may just be so delayed that now they can't actually take off because duty times require that they get a new flight crew in and so on.
[SPEAKER_02]: But in any case, they were really trying not to have to get out of this long line and then join the back of it again.
[SPEAKER_02]: And then lastly, the NTSB found that there was a failure to abandon the takeoff, even after they detected that there was an inadequate amount of power that was being developed.
[SPEAKER_02]: And so really what happened here was there was an inadequate amount of power being developed on takeoff with the Isas well, which meant that the aircraft didn't have enough speed or power to actually fly properly.
[SPEAKER_02]: It's stalled and it crashed into a bridge.
[SPEAKER_02]: Neither pilot had significant experience in winter, icy conditions, because they're both relatively junior in their careers and both from Florida.
[SPEAKER_02]: From an analysis point of view, one of the quite interesting parts from this was that they had to create an entirely new method of detection in terms of determining how much power the actual engines were created, because they had the indication in the cockpit, but they actually had a different sound in the cockpit voice recorder.
[SPEAKER_02]: And so one of the NTSB investigators was able through a lot of effort on their part to determine through the sound that was generated on that cockpit voice recorder that they were actually only developing about 70% of the power that they were supposed to.
[SPEAKER_02]: And that was enough to get the aircraft airborne, but not enough for it to climb out.
[SPEAKER_02]: Then just to finish it up, the aircraft just didn't have enough power to climb out.
[SPEAKER_02]: The aircraft was airborne for about 30 seconds.
[SPEAKER_02]: It crashed into the 14th street bridge across the Potomac River at the end of the runway.
[SPEAKER_02]: The aircraft hit six cars and a truck on the bridge, it tore away about a 30-meter section of the bridge's rail and then it slayed into the Potomac River where rescuers attempted to pull survivors from the river and the wreckage and that's why only four people survived.
[SPEAKER_02]: And then, of course, we'll see this in other aircraft accidents, but due to those really bad weather conditions, the air traffic controllers did not initially know that the aircraft had crashed.
[SPEAKER_02]: They only knew that it just wasn't showing up on the radar screens and wasn't responding to radio calls.
[SPEAKER_02]: One person at that time jumped into the river to save passenger that night.
[SPEAKER_02]: And again, I'll just point to so the first officer at the time asked how much ice was on the wing on the captain's side before they took off.
[SPEAKER_02]: The captain replied, I got a little bit on mine.
[SPEAKER_02]: However, the first officer said a little, this wing's got about a quarter to a half an inch on it all the way, which is a lot of ice.
[SPEAKER_01]: To recap this situation, Adam, this is a flight going from Washington, which is very cold and I see at the time to Florida, which is much further.
[SPEAKER_01]: Unlike the other accents we talked about, this one occurred at the very beginning of takeoff.
[SPEAKER_01]: So the plane actually got airborne, it experienced some significant issues with actually getting up to speed and is safe as sent pattern.
[SPEAKER_01]: Because of the issues with the icing and because of other mechanical issues, we'll say the plain took off and then crash almost immediately after because of ice being on the wings and in the engine and providing some issues there.
[SPEAKER_01]: Your point about identification about suboptimal function deviating off the beaten path for expedience here are certainly well taken and it's actually a tragedy how many people died so close to the airport.
[SPEAKER_01]: when it seems like they were multiple indicators that either the polish should not have been doing what they were doing or should have aborted their flight given the feedback they were receiving.
[SPEAKER_01]: Is that more or less correct?
[SPEAKER_02]: Yes, and I will say one thing that I haven't mentioned earlier, which when the pilots set take off power.
[SPEAKER_02]: There was an indication in the cockpit that they were developing the power that they thought they were.
[SPEAKER_02]: So it's important.
[SPEAKER_02]: A large commercial owner, you don't just push full throttle and take off.
[SPEAKER_02]: You have to protect the engines and you just can't do that, right?
[SPEAKER_02]: And so the indication in the cockpit was on the gauges that they were developing the power that they needed to take off.
[SPEAKER_02]: However, the sound of the engines and the fact is that the engines were not developing the power that the indicator was ringing.
[SPEAKER_02]: The indicator was falsely reading high.
[SPEAKER_02]: And the first officer tries to bring the captain's attention to this and that's ignored.
[SPEAKER_02]: The reason that this falsification happened was because of the failure of the pilot's turn on the anti-IS system.
[SPEAKER_02]: of the actual engines itself, and that may have been exacerbated by this unconventional procedure of trying to use reverse thrust to actually back away from the gate and so on.
[SPEAKER_02]: But there were a number of factors.
[SPEAKER_02]: The main ones you already mentioned, the significant ice on the actual wings, the false indication in the cockpit, and then the actual failure to develop the appropriate power and so on.
[SPEAKER_02]: Again, as we saw in some of the other accidents, the National Transportation Safety Board was not satisfied with merely providing guidance on how to avoid that approximate
[SPEAKER_02]: This unconventional procedure of using a previous or preceding aircraft's jet exhaust to try and blow the snow off and so on.
[SPEAKER_02]: We see that
[SPEAKER_02]: There are other pilots that may have thought that this was an appropriate procedure, and we see now we have hard evidence now that not only is not a good procedure that it actually makes the problem worse by re-freezing the ice farther back.
[SPEAKER_01]: What do you see as the perils from this accent to the alien romney case?
[SPEAKER_01]: This feels a bit different than the other ones, but I'm hoping you can shed some light as to why you decided to include this one in particular.
[SPEAKER_02]: So, it's funny because
[SPEAKER_02]: I didn't do a keyword search for these things.
[SPEAKER_02]: These are the accidents that came to my mind when I heard about the alien broadly case.
[SPEAKER_02]: I just remember that there were accidents that have these features in them, and this is why we do things in this way in aviation.
[SPEAKER_02]: For me, this accident stands for the proposition that first officers would choose to risk death over counter-manding the captain.
[SPEAKER_02]: And so we look at some of the nurses and some people might wonder, well, why didn't they do more in the alien ramen case?
[SPEAKER_02]: They knew what was going on, why didn't they do more?
[SPEAKER_02]: Well, can you really expect them to do more?
[SPEAKER_02]: Especially when we don't know what tools they had if they're disposal.
[SPEAKER_02]: We don't know what training they had in terms of escalating their language of concern.
[SPEAKER_02]: We're going to talk to some other physicians later on about these things.
[SPEAKER_02]: We don't know what tools they had.
[SPEAKER_02]: We also don't know how well supported they would have been at that hospital.
[SPEAKER_02]: And we really expect anything more from those nurses when we've seen 50 years ago, first officers would literally choose to risk death.
[SPEAKER_02]: And remember, the first officer did in fact die in this case, the captain died in this case.
[SPEAKER_02]: The first officer here, voice concerns about the antibodies on the wings and the amount of power that the engines were developing versus what the gauges were reading.
[SPEAKER_02]: And again, these concerns were not acted upon by the captain.
[SPEAKER_02]: And at the time prior to what they called cockpit resource management at the time, which they didn't even have back then, the captain's word was law, it was final.
[SPEAKER_02]: And people in airlines needed to understand that lack of empowerment of first officers was directly resulting in deaths.
[SPEAKER_01]: This case speaks to so many broader issues in medicine that really resonate with me.
[SPEAKER_01]: I think there's certainly something to be said about people not speaking up or people feeling unempowered to speak up or people disregarding the comments of their junior colleagues.
[SPEAKER_01]: In the Elaine Bromley case, we can talk about now that we pre-action in patients very well.
[SPEAKER_01]: But at the time, I'm sure there was some discussion and this may have been routine for the physicians operating not to pre-action in patients.
[SPEAKER_01]: Just as this may have been routine for the captain in the first officer to do these things that they've done and they've gotten away with them so many times, this is the case that they weren't able to get away with it and it shows that this may have been poor practice from the very beginning.
[SPEAKER_02]: You know, there's a point here where it's not just a practice and I agree with you on that point about what's routine practice, what do we do now that's different than before.
[SPEAKER_02]: But there's a commonality that I don't think we've talked about yet in some of these, which is the interpersonal relationship between the pilots in the room.
[SPEAKER_02]: And I think you were touching on this a little bit when you were talking about
[SPEAKER_02]: assertiveness and empowerment of nurses.
[SPEAKER_02]: There is any high-functioning team, whether it's in the cockpit or with the flight crew, which includes the cabin crew in aviation, or whether it's on a resuscitation team or any of these things.
[SPEAKER_02]: There are the things that we do, and there's the manner in which we do them, that matter, and that's whether it comes to communication or anything else like that.
[SPEAKER_02]: And when we do, for example, advanced cardiac life support or ACLS or any of these things, where we're trained to resuscitate patients,
[SPEAKER_02]: the drugs that we push and the sequence in which we do things, we also talk about team performance and so on.
[SPEAKER_02]: But when we look at these accidents, we also now talk a lot about how people solicit information, whether they solicit information, how they interact with people, and when this idea of true resource management came out in aviation,
[SPEAKER_02]: There was a pushback to it and we'll get into this in a later episode because we are going to talk to airline pilots about this about how CRM came to be.
[SPEAKER_02]: And one of the big pushbacks was that captains felt that this was an encroachment on their legal and moral obligation to protect the passengers on their aircraft that they were literally in command of.
[SPEAKER_02]: And they felt that they didn't quote unquote need to go to charm school.
[SPEAKER_02]: and so it was really seen as this fight as to who's really in charge.
[SPEAKER_02]: Am I going to give this person that has less time than me to say on what happens on my aircraft?
[SPEAKER_02]: And it was really because of accidents like this where we see that
[SPEAKER_02]: captains are fallible.
[SPEAKER_02]: They are human and by their very nature of that, they need to be able to understand that sometimes they don't have the full picture and sometimes they need to take in information from other people.
[SPEAKER_02]: And so it's not just that they need to take information, but it's the manner in which they do that.
[SPEAKER_02]: It's also the environment which they create.
[SPEAKER_02]: And we, as physicians, can do that so that we can create an environment where, as we talked about earlier in the episode, have the most junior person, whether they're a medical student
[SPEAKER_02]: feel like they can say something and that's really important and we do talk about that a bit in medicine but we don't have this rich data set to pull from where we see that people have literally died because of the manner in which the leader was conducting themselves.
[SPEAKER_01]: And I think the last point you said about the mechanisms of investigation, liking a medicine really is I think the overall arching theme of this episode of reflecting on the issues that happened in medicine.
[SPEAKER_01]: I think there's a lot to be said about medicine taking a step back and getting out of that headspace that were unique that this is medicine that we have at moral and needle responsibility to save lives and things aren't the same.
[SPEAKER_01]: In other places, it is actually just to say that although our practices unique and what we do is in the necessarily same thing as flying an airplane, let's say, but we can still take a lot of lessons.
[SPEAKER_01]: As an anecdote, when people ask me what I do for a living, I say I fly a private aircraft for passengers of one because I feel like that's what anesthesia is, right?
[SPEAKER_01]: We're there, I take off the landing and we ensure that people who are taking their health care journey are saved throughout the time that they're in our care.
[SPEAKER_02]: I had a lot of frustration when I joined medicine because I came from this aviation environment.
[SPEAKER_02]: And it's almost like in some ways aviation is 50 years ahead in terms of how it investigates accidents and how it talks about some of the interpersonal relationships and things like that.
[SPEAKER_02]: And we're gonna see when we talk to airline captains about how we're on to six generations CRM now.
[SPEAKER_02]: I think it's really important that we look back and go, this didn't happen overnight in aviation.
[SPEAKER_02]: It's not gonna happen overnight in medicine.
[SPEAKER_02]: There were airline captains that were vociferously against the concepts that we now take for granted in aviation.
[SPEAKER_02]: because it was brand new and it was seen as charm school and it was seen as a new intervention that seems very soft skill.
[SPEAKER_02]: You know, I need to know how to land an airplane.
[SPEAKER_02]: Don't tell me how to leave my crew kind of thing.
[SPEAKER_02]: Almost like some people might say in the operating room, I need to learn how to intubate.
[SPEAKER_02]: Don't tell me how to let somebody else intubate or choose a different path or what have you.
[SPEAKER_02]: I think it's really important to acknowledge that this was not an overnight success in aviation.
[SPEAKER_02]: It certainly isn't gonna be an overnight success in medicine.
[SPEAKER_02]: You can't just take the same intervention from aviation and plop it down and say here you go now you have CRM it is a journey it is going to take years and it's going to take a mindset shift as well as the tools.
[SPEAKER_02]: both in terms of investigation tools, but also in terms of outcome measures as well.
[SPEAKER_02]: It's very hard to measure these things in aviation to know that we're succeeding and so on.
[SPEAKER_02]: And these are all things that I hope to talk about in future episodes, but please don't think that we're looking at this and saying, oh, well, if they only put black boxes in operating rooms, and if we only decided that we would look at what we're looking at in terms of the analysis of interpersonal skills, if only that doctor was kinder, then we wouldn't have these problems.
[SPEAKER_02]: That is not the answer that we're talking about here.
[SPEAKER_02]: went over a 50-year period and how we might be able to shorten that time to being less than 50 years in medicine.
[SPEAKER_01]: I have nothing to add.
[SPEAKER_01]: There's nothing that I can say to improve on my concept.
[SPEAKER_01]: So, as we, I think that's a great place to end this episode.
[SPEAKER_01]: So, quick summary of what we talked about today if you don't mind and then we'll wrap up there.
[SPEAKER_02]: So just to summarize the episode, we talked about the Elaine Bromley case, we talked about this fixation induced loss of situational awareness in the operating room that resulted from a failure of leadership in a breakdown of communication where Elaine, who was 37, and healthy died from a can-indibate can-oxidate scenario when the positions perseverated on intubating rather than following what they're training told them to do, and what the nurses were trying to tell them to do.
[SPEAKER_02]: We saw that human factors in that case and not technical proficiency are what killed Elaine Bromley and as her husband Martin Bromley put it, it was the system that failed and he commissioned that report to help others.
[SPEAKER_02]: We then looked at the overall aviation accident investigation system in North America where we have independent bodies that investigate accidents with a view to preventing future ones.
[SPEAKER_02]: We saw that a report on those accidents is made public so that others can learn from it and their recommendations to a variety of stakeholders including airlines, flight training, airframe, engine manufacturers, air traffic controllers and of course the regulator as well.
[SPEAKER_02]: We saw that there is a watch list of common issues across multiple accidents.
[SPEAKER_02]: So for example, 10 years down the road, they'll say, well, we've had fatigue on the watch list now for over a decade and Canada at the time, for example, lagged behind a lot of other countries in terms of how many hours they allowed pilots to continue flying.
[SPEAKER_02]: We then discussed three well-known aviation accidents that, in my view, parallel to the land-brownly case, we saw Eastern Airlines 401, which was a fixation-induced loss of situation awareness on that L-1011, where they had the nose gear landing light.
[SPEAKER_02]: They were trying to troubleshoot it, an uncommended deviation in altitude, over unlit terrain, and the pilots missed that altitude alert chime, and they missed the fact that the air traffic controller was trying to tell them they were too low, and they crashed.
[SPEAKER_02]: We saw United Airlines Flight 173, which was around the Portland area.
[SPEAKER_02]: Again, a landing gear light problem, where the aircraft was just flying over an hour, trying to fix this problem in a Renault of fuel and crashed.
[SPEAKER_02]: And then we looked at Air Florida Flight 90, which was January 13th of 1982, where the crew pushed ahead into poor icing conditions, and they had an indicating problem in the cockpit thinking that they were developing more power than they really were because they didn't turn on the anti-IS systems of the engine, but they also had too much ice on the wings, despite the first officer mentioning both of these things, the captain pushed ahead and a number of people died.
[SPEAKER_01]: In the next episode, we'll have a special guest on Captain Mike Schuster.
[SPEAKER_01]: He'll be discussing how aviation interests the shortcomings that were identified in the accents that we discussed today, specifically he'll talk about cockpit resource management and how it's involved over the past decades.
[SPEAKER_01]: A few safety interventions worth mentioning, like we try to do every episode, today's interventions, the pulse of summer that was invented by Dr. Ayogi of Japan, hopefully it's had a same correctly.
[SPEAKER_01]: So this is based off of principles developed by Professor Carl Mathes in Germany in 1935.
[SPEAKER_01]: The actual Paul Siximiteric self was introduced in 1972, but Dr. Uyagi, but it wasn't adopted as the standard of care and anesthesia until 1980.
[SPEAKER_01]: I still work with very elderly attending anesthetists who try to tell me about a time before Paul Siximiter's were invented and that just seems almost like a fictitious.
[SPEAKER_01]: What we can do tomorrow to improve health care systems going forward for practitioners will flatten the hierarchy and get to new universities and doctors.
[SPEAKER_01]: There's some evidence that shows that when we
[SPEAKER_01]: use first names of our colleagues in health care settings.
[SPEAKER_01]: We actually run into less layers in the OR, we'll link that paper or the discussion in the show notes if I can find it.
[SPEAKER_01]: Encourage verbalization of thoughts by actually seeking input.
[SPEAKER_01]: Does anyone have any other ideas?
[SPEAKER_01]: How does that plan send to you with this particularly salient in codes?
[SPEAKER_01]: And if leading a resuscitation, consider delegating macro tasks that will offer mental load on you, we'll have a different episode on task saturation.
[SPEAKER_01]: The future will get into more details about that.
[SPEAKER_02]: A lot of times we've been trained to do some of these things that we would otherwise call CRM.
[SPEAKER_02]: Things like closed loop communication where you repeat back.
[SPEAKER_02]: So I'll say a give 10 milligrams of metacloprimide now.
[SPEAKER_02]: And the person is supposed to say, okay, I'll get 10 milligrams of metacloprimide by ID now.
[SPEAKER_02]: And it's a bit cumbersome, but these are the kind of
[SPEAKER_02]: We've been trained that way, but in practice it may not happen that way, but I saw a nurse in a resuscitation in sick kids, she asked someone to do something, and the person just said, okay, I'll do it, and she can, I get some closed loop, and I thought sometimes I like to stick those things in my back pocket, and so literally yesterday I was working at a hospital, and this person had diabetes, and I was in the operating room for a different patient, and the nurse asked for a verbal order for insulin, and
[SPEAKER_02]: And I said, OK, can you give insulin 10 units of insulin R sub you now?
[SPEAKER_02]: And there's said, OK, and I said, well, sorry, I just need to read back on that.
[SPEAKER_02]: And she goes, OK, and then she read it back to me.
[SPEAKER_02]: And I'm later on, I went to her and I was like, hey, listen, I'm, you know, sort of be a, you know, that way and so on.
[SPEAKER_02]: insulin is just one of those drugs where I just really really want to make sure that we're given the right amount so it wasn't like this was a recession or anything but sometimes you just say kind of get closed loop or kind of just get a rebound on that and then we both know what was said just thought I pointed out sometimes it's not a failure of knowledge it's more a failure of practice.
[SPEAKER_01]: totally, and for the less assertive of us in the room, I like to say things long lines of, can you repeat that back just to make sure that I spoke clearly or that the connection was not interrupted or whatever the case may be, that way you awful the responsibility of someone doing a more formalized house, can you actually make it more personal and more communicative, and I feel like that lowers the threat threshold significantly.
[SPEAKER_01]: Anyways, now on our
[SPEAKER_01]: Fun suggestions, random recommendations, Adam already mentioned the accurate podcast.
[SPEAKER_01]: I'll make a plug for the book I've been reading over the past several months called Radical Acceptance by Tara Brock, a great book about just facing difficulties in being more mindful in your life.
[SPEAKER_01]: I've certainly found it particularly useful when managing the personal challenges of just carrying the duality of medicine and things like that.
[SPEAKER_01]: I've got a check that out, I've got a check that out.
[SPEAKER_01]: Adam?
[SPEAKER_02]: Read recommendations.
[SPEAKER_02]: I've been listening to the CBC podcast.
[SPEAKER_02]: It's called C. You in court.
[SPEAKER_02]: They're usually half an hour.
[SPEAKER_02]: They're about landmark Canadian cases that really change the legal landscape.
[SPEAKER_02]: But also, they're usually on big, thorny issues.
[SPEAKER_02]: And they do a really good job of not just presenting the legal arguments here and there.
[SPEAKER_02]: And what was actually done legally.
[SPEAKER_02]: But also, it's put up by the CBC, the Canadian broadcast and corporation.
[SPEAKER_02]: So they often have, well, this was a 50 year old case.
[SPEAKER_02]: And they'll say, well, we had a man on the street episode.
[SPEAKER_02]: And let's go and listen to what people were
[SPEAKER_02]: at the time.
[SPEAKER_02]: So I just, I find it really interesting.
[SPEAKER_02]: They managed to follow up with the human interests side of things, not just the legal side of things, highly, highly recommend it.
[SPEAKER_02]: I think they just finished their first season.
[SPEAKER_02]: I hope they have another one.
[SPEAKER_01]: Awesome.
[SPEAKER_01]: Thank you Adam.
[SPEAKER_01]: That's it for today's episode of the Medical Safety podcast.
[SPEAKER_01]: I'm a mirror hammered.
[SPEAKER_01]: And I'm Adam Shahed it.
[SPEAKER_01]: And Adam loves this as one TV doctor said, one, you have to say it.
[SPEAKER_00]: It's beautiful.
[SPEAKER_00]: They
[SPEAKER_03]: All right.
[SPEAKER_03]: Well, I love that sign off.
[SPEAKER_03]: It's a beautiful day to save lives fabulous fabulous and I really appreciate these guys putting the work into starting this podcast and the goal of really helping us as a specialty and as an institution in medicine to improve the way we do patient safety is a great one, especially because they're doing it as you just heard in a really interesting way keeping the episodes interesting, exciting to listen to and also drawing really really important lessons from.
[SPEAKER_03]: their expertise in aviation in other areas.
[SPEAKER_03]: So I look forward to more and I hope you do too.
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[SPEAKER_03]: It'd be great if you guys could support them a little bit.
[SPEAKER_03]: It's going to be worth it as they get this thing up and running.
[SPEAKER_03]: All right, hopefully you got as much out of that as I did.
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[SPEAKER_03]: All right, that is it for today.
[SPEAKER_03]: For the ACRAG podcast, I'm Jed Wolpa.
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