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Protocols for Structured Communications- a New Pathway to Reliable Systems in Aviation and Healthcare?

2009/11/12

Recently a Northwest Airlines flight went past its destination by 150 miles because the two pilots were arguing, distracted, tired, or busy with their laptops.  Fortunately the mistake caused no harm; after realizing their error the pilots flew the plane back to its destination.  This is called a “near miss” in aviation- it was an incident that could have caused harm but didn’t.  The NTSB (National Transportation Safety Board) investigated and announced that the pilots had “lost situational awareness.”  Should the flying public be reassured by this? 

 To find out, we need to know what the heck is meant by “situational awareness.”  Is it a polite way of saying “they fell asleep?”  Maybe.  This term has very specific reference in aviation safety.  It can mean someone is fatigued and falling asleep, or it can mean they are losing attention, or they have lost track of the flight plan and where they are (for any reason).   In any event, pilots and flight crews are trained in a discipline called “Crew Resource Management” which provides them with an understanding of typical flight situations, recognition of what they are supposed to be doing at given points along the flight plan, and things to do if they feel they are losing awareness of the plan or their role in executing it.  Specifically, pilots and crews are trained in using structured techniques and protocols for communications when they lose situational awareness.

 One example of such a protocol is “callouts.”  In Crew Resource Management, pilots and crews are trained to use a numeric scale to structure their communications if they lose situational awareness.  For instance, “Zero” can mean “I know what I’m doing; I’m centered; I’m OK with what is going on.”  “Minus 1” and “Minus 2” can mean “I am losing situation awareness,” then “I have lost situation awareness.”  Plus 1 and 2 usually refer to heightened concern about the situation, as in “I think I know what’s happening and I’m concerned about it”, then “I am really concerned about what is happening.”  In rehearsals and simulation, flight crews practice using these techniques to let each other know they are concerned or they are losing touch with the situation.  Either scenario calls for recalibration and corrective action; but it all begins with shared recognition and assessment of the situation by more than one crew member.

Why does any of this matter?  Isn’t it stating the obvious?  Not necessarily.  In many accident investigations, the NTSB and other investigatory agencies have found that one or more crew members knew there was trouble before the accident actually happened, but were afraid to speak up because they were junior in rank, or because others would think they were “crazy” or incompetent.  As a result, they did not share their concern and the accident happened.  (The case of the faulty O-rings on the Challenger is an example of this recurring human barrier to safety.)  Structured communications techniques, along with briefings and debriefings, are meant to counteract this fear and provide a safe way for anyone on the crew to raise an issue or concern in time for it to be addressed.

Were such techniques used on the Northwest flight in question?  It is hard to tell from the media reports, but we do know that the pilots learned of their mistake when a flight attendant called from the cabin to ask whether they had overshot their destination.  From the published reports, we do not know what he or she said; nor do we know if this was the first attempt to call the pilots’ attention to their mistake. We do know, however, that practicing such techniques in advance makes it more likely they will be used at a time of danger or crisis.

Here is an example from a different industry- healthcare.  A colleague of mine and I have worked with a hospital in Illinois for the last five years to implement high-reliability teaming strategies, adapted from other high-consequence industries like aviation.  We have worked with anesthesia, the operating room, and the Emergency Room, all of whom were attracted to the idea of team-based care but were confused about how to implement it effectively in their environment.  One thing was used was the call-out mechanism for structured communications during surgical procedures.  They liked the structure but wondered how to implement it.  One of our colleagues, Dr. Michael Leonard (Director of Patient Safety for Kaiser Permanente at the time), said “At Kaiser, we recommend that when people lose situational awareness, they say ‘Can I get a little clarity?’”  As an outside observer, I found it amazing that this kind of statement could get anyone’s attention in a busy and stressed operating room; but the anesthesiologists, technicians, and nurses in the audience felt right away that this would work for them.  Evidently having a script, or statement they could make with prior agreement, was sufficient for them to feel more confident about speaking up at a “moment of truth.”

This kind of intervention will not work as a “checklist”; it needs prior discussion and adaptation to the specific work environment.  But perhaps it provides some clues to how we can prevent future incidents (and potential accidents) like the one at Northwest Airlines, and also create higher-reliability systems of care in operating rooms and emergency rooms.

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