Intended for healthcare professionals

Press Personal views

Blunders will never cease

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7285.563 (Published 03 March 2001) Cite this as: BMJ 2001;322:563
  1. David Johnson, senior route check captain
  1. British Airways

    See pp 501, 517, 548, 562

    Bored and having been awake through jet lag from 3 am, I turned on the TV in my hotel room in Denver. I had arrived the day before and would that day leave for London: a routine trip for an airline pilot. A rather handsome man appeared on the screen. It was David Lawrence, chairman of Kaiser Permanente Medical Group, the largest non-profit healthcare organisation in the US, but he was speaking about aircraft crashes. He stated that in the United States from 1950 to 1990 commercial aviation fatalities fell from 1.19 to 0.27 per million departures—an 80% reduction in the face of a dramatic increase in the volume of air traffic. I forgot about breakfast and watched the speech.

    The experience of aviation shows that we can help the NHS understand safety problems

    Dr Lawrence made six points about standard aviation safety practice. These included statutory reporting procedures, a voluntary (without jeopardy) reporting culture, recurring statutory examinations, systems, safety analysis of data, and the acceptance that pilots will make mistakes. Incredibly Dr Lawrence described how the safety practice norms of the aviation industry were anything but routine in health care.

    When I returned to the UK I thought how the safety issues Dr Lawrence was talking about could be shared with medical practice. Despite obvious differences, there are parallels between aviation and medicine. Consider the position of pilots more than a decade ago, before crew resource management (CRM) team skills training and testing were introduced. The captain was basically God. While a humble co-pilot's opinion might or might not have mattered, once promoted to captain, the same individual's view was inviolate. Can you imagine the affront to senior captains' dignity when crew resource training was introduced? They were asked to put aside their hard earned status and accept questioning from “junior” pilots, a shift from autocrat to team player. Yet now, even the most dyed in the wool “Atlantic baron” is convinced of the value of teamwork and of teamwork training—a radical change in culture.

    CRM training was developed as it became apparent how team skills, or the lack of them, were key factors in air safety. Too many crashes had been recorded as due to error by the pilot or crew, with all the stigma of blame; and the public, the regulators, pilots' associations, and commercial operators all demanded a deeper investigation into the reasons behind the apparent breakdown of crew working.

    The examples are public. A large difference of opinion between the pilots during the let down phase of a Dan Air 727 flight over Tenerife led to all those on board being killed when the aircraft hit a mountain. A Trident stalled over Staines when the leading edge droop devices were retracted at too low a speed, probably because an assertive captain ignored the views of other pilots. There are many other examples. Just as important, good teamwork has been shown to help in avoiding accidents.

    The value of CRM training is unquestioned today. Recurring statutory checks and tests include crew teamwork elements in the regular simulator and route check tests for all pilots. Pilots now accept that professional competence in CRM is as important as their technical knowledge and flying ability.

    Contrast this with the culture within medicine of finger pointing, reinforced by a blame based malpractice ethos. Moreover, the regulatory and legal environment in which the modern health service operates is remarkably complex and confusing. Yet Dr Lawrence explained that in the US few healthcare organisations had begun to use human factor and safety system engineering or provided safety related training for their clinicians. Today's NHS has no formal team skills training or goes anywhere near adopting the safety procedures that work in aviation.

    Medicine embraces an expectation of perfect performance, even though the evidence clearly argues for a different conclusion. This reinforces the culture of individual blame and increases the difficulty of putting team skills training in place. The experience of aviation shows, however, that we can move away from the horror stories to help NHS staff understand the problems of safety, why disasters happen, and how we can make improvements to our behavioural practices. The first steps are to understand, firstly, that accidents nearly always occur because of system failures (human or otherwise), not malice, stupidity or incompetence, and, secondly, that to understand why an accident has occurred usually requires tough analytic endeavour.

    Clinical governance is a stride in the right direction but not enough by itself. Training in behaviour that promotes safety is as important as, and complementary to, reactive analysis after the event. I believe medicine can learn something from crew resource management training. And if you feel that such training is something for the nursing staff but not for you then maybe you need teamwork training most of all. I know, I've been there.

    Competing interest: DJ is a founding partner of TEREMA, a group of pilots and doctors who run courses on team resource management (01481 7241441, 0802 225835).