With Errors: Aviation Blames The System, Healthcare Blames the Individual
NTSB Finds ‘Blind Spot’ in SFO Radar After Near-Miss to Aviation’s Greatest Disaster Reports the Mercury News: “The wayward Air Canada plane that nearly caused an aviation disaster at San Francisco International Airport [on July 7th] dropped off radar displays for 12 seconds in the moments before it approached four fully loaded passenger jets on the taxiway, according to new information released Wednesday from federal aviation officials investigating the incident. A source familiar with the investigation called it a “blind spot” that is a half-mile from the start of Runway 28-Right and Taxiway C.”
In Aviation, when a near miss of a catastrophic error takes place everyone including pilots, airline companies, government agencies, passenger witnesses, air traffic control and airport administration, all work together on a federal level through the NTSB and the FAA to find the cause.
On average it takes at least seven mistakes to cause a catastrophic error in aviation, so there’s lots to learn from dissecting a near miss. Luckily its not the 1950s and investigators have the help of blackbox recorders, video surveillance systems, team-based communication protocols, and practiced simulation at work in the aviation industry to maximize safety effectiveness.
Even if a single individual’s actions are to blame, in aviation the investigation is to find out the cause within the system with the ultimate goal going beyond the singular blame to an educational and training requirement program change. An individual who failed at this level exposes a failure of the system somehow, and that we all agree is a good thing to admit and fix. And in the case of the Air Canada Flight AC759, it only took a month to expose a systematic failure.
What happens in healthcare when we go up to and beyond catastrophic errors? Individuals are usually blamed and systematic errors rarely corrected. Hospitals hide infection rates, and medical error is always an acceptable means of patient death. Where is Healthcare’s NTSB and FAA? Where are the OR black boxes? Where are the mandatory hand-washing video recording systems? Our legally required simulation training quotas and check off performance demonstrations? Or any major media coverage of every single medical error patient death? And most of all…
Why do we let this keep happening?
Lance Baily, BA, EMT-B, is the Founder & CEO of HealthySimulation.com, which he started while serving as the Director of the Nevada System of Higher Education’s Clinical Simulation Center of Las Vegas back in 2010. Lance is also the Founder and acting Advisor to the Board of SimGHOSTS.org, the world’s only non-profit organization dedicated to supporting professionals operating healthcare simulation technologies. His new co-edited Book: “Comprehensive Healthcare Simulation: Operations, Technology, and Innovative Practice” is available now. Lance’s background also includes serving as a Simulation Technology Specialist for the LA Community College District, EMS fire fighting, Hollywood movie production, rescue diving, and global travel. He lives with his wife Abigail in Las Vegas, Nevada.