Aviation & Healthcare : Polish President Air Accident

Just finished watching an episode on Discovery Channel about aviation disaster in Poland, in which their President died.  The scenario looked so similar to errors in healthcare, about which I was reading today itself.  In that incident a Russian made plane crashed while landing at a Polish military airport.  It was flying low and brushed over trees and overturned and crashed before it could touch the runway.  It was foggy and the pilots were faced with very poor visibility.  Now, I will highlight the errors that were made on that flight

  1. Their altitude indicator was not working properly.  From the flight data recorder it was found that they were flying lower than what their instruments told.  It was found that as it was a military airport, its elevation above ground was not in plane’s database.  On top of that the pilot had deliberately set the elevation a bit higher, to avoid “nuisance” warning that go off when the plane is dangerously low.  A sure sign of over confidence by probably the best trained pilots.
  2. From the cockpit voice recorder they found that there was some unauthorized person in the cockpit.  Most likely it was some senior official as it was a VIP flight.  It could be concurred that that person was putting indirect pressure on the pilots, adding to their stress.
  3. Also, the captain of the plane was also doubling up as navigator, which added to his workload. 
  4. In addition to the altimeter, which was faultily set, the navigator also had radio altimeter.  Investigators wondered why the faulted when they had redundancy in the form of radio altimeter.  They later found that the plane encountered a valley on its approach to the runway, and then sudden elevation.  That fooled the pilots into believing that they were flying high when they were not.
  5. The investigators also wondered why the captain didn’t decide against landing in such weather, even thought it was his final call.  They wondered that he was under indirect pressure from officials in the cockpit.   Also, he has had a previous experience as a co-pilot, where the captain refused to land a VIP flight due to safety, and the latter was reprimanded for it.  Surely, this thing was lingering in his mind and didn’t want anything to affect his career.
  6. They wondered why the air traffic controller (ATC) at the airport didn’t warn the pilot against landing and suggest a go-around.  It was later found that the instruments at ATC weren’t working properly.  More importantly, even though ATC was acutely aware of the risks involved, they didn’t have the authority to divert the flight.  Had it been any other flight, they would have, but not the one with VIP onboard. 

Now coming to similarities with errors in healthcare industry.  This seems to be a classic case of “Swiss cheese” theory, where multiple errors, all happening at the same time and redundancies not working.  Interpreting each point individually,

  1. No matter how well trained and experiences a professional you are, you must not ignore the safety built into standard operating procedure.  Errors often happen by most experienced people, as less experienced exercise caution.
  2. This point emphasized the importance of stress-free environment at workplace.  Like aviation, efforts should be taken in hospitals such that staff does not get stressed.  Also, management should leave the technical stuff at the hands of the experts, and be in a more of a supportive role.
  3. Efforts should be made such that workload is evenly distributed among workforce.  In LEAN terminology, it is called leveling.
  4. It is again a case of Swiss cheese theory, where two holes were aligned and they contributed towards the accident.
  5. Clubbing point 5 & 6 together:  There was indirect pressure on both pilot and ATC.  Unlike the workers of Toyota Motor Co, who are empowered to stop the production line, they had no say in such a critical matter.

Ultimately, errors happen when redundancies built in go wrong and it is too late to act.

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