In healthcare patient safety circles, there’s always a lot of discussion about lessons learned from aviation safety. Aviation has gotten much safer over the past few decades, while each new study done in healthcare indicates the patient safety problem is not getting better (or is getting worse… or is being measured better).
I realize that some people in healthcare get just as annoyed hearing about planes and cockpits as they do hearing about Lean manufacturing and factories. We take it for granted now that aviation is safe. There are many annoying things about flying and baggage might get lost… but you’re very unlikely to die in a plane accident, even flying 120,000 miles a year, like I do.
So it begs the questions – what the heck is happening in aviation? Why have two planes in recent months landed mistakenly at the wrong airport?
Dreamlifter pilot who landed at wrong airport ‘couldn’t read his handwriting’ and got confused between east and west
In November, a Boeing “Dreamlifter,” a modified 747 used for moving huge aerospace parts around (probably not a Lean practice), landed at the wrong airport in Kansas.
In a terrifying radio exchange just before landing a massive 235 ft cargo plane at the wrong, and tiny, Kansas airport late on Wednesday, the pilot sounded confused.
The man could be heard mixing up east and west, saying he could not read his own handwriting and getting distracted from the conversation by ‘looking at something else.’
This is “human error,” but it’s really surprising that there isn’t better technology or better systems (involving double checks, etc.) to prevent this from happening. While nobody got hurt or killed, it’s still a serious incident to be investigated and understood, so it doesn’t happen again. Preventing situations like this requires approaches other than just blaming or punishing the pilot and co-pilot.
And now from this week:
A Southwest Airlines flight from Chicago bound for Branson, Mo., landed safely at a different nearby airport, the airline confirmed Sunday night.
Southwest spokesman Brad Hawkins said Flight 4013 from Midway landed safely and without incident at M. Graham Clark-Taney County Airport, which goes by the three-letter airport code PLK, instead of as scheduled at Branson Airport, BKG, a short distance away.
The Boeing 737-700 carried 124 passengers and a crew of five, the airline said.
Again, nobody was hurt, but that’s not an excuse to just move on without an investigation. It was a major mistake and possibly a “near miss” from a safety standpoint. Does your hospital take such “near misses” as seriously?
It’s too early in the investigation (as of Monday) to know what the cause of the problem was… do any pilot readers have any thoughts on this? I’ll try to scan the news for updates and more details about why this happened.
Why did the plane land at the wrong airport? There’s a good “5 whys” and root cause analysis to go through here.
Yesterday, the pilots were suspended. But aren’t the pilots part of a broader system?
In a statement Monday, Southwest said the two pilots had been placed on paid leave, pending the conclusion of an investigation. The captain on the flight is a 14-year Southwest employee, and the first officer has been with Southwest for 12 years, the company said.
But pilots are not the only ones who can be blamed for such blunders, said Tom Reich, an aviation expert involved in airport management for AvPORTS Management LLC. Air traffic controllers can warn pilots if they appear to be heading for the wrong airport, he said.
So why could this have happened?
So how does a modern, computer-laden, GPS-equipped 70-ton passenger jet end up at the wrong airport?
Pilot error, said aviation expert Mary Schiavo: failure to monitor the plane’s instruments and not paying attention to runway numbers and other visible variables.
It happens — primarily in good weather, Schiavo said – when pilots opt to “hand fly” their jets instead of allowing onboard computers to do it.
“If they had been flying on instruments, it would have taken them straight in (to the right airport),” said Schiavo, former inspector general at the U.S. Department of Transportation and now a private attorney who represents victims of air crashes.
Was the error landing on the wrong runway (the result) or was the error choosing to “hand fly” (the process choice)? Schiavo says wrong-airport landings are “fairly common.” That screams “system problem” to me. If we don’t fix the system, it will happen again.
Aviation Errors and Medical Mishaps
Will aviation do more to prevent a third such incident than our health system will do to prevent wrong-site surgeries and major pathology errors that keep happening again and again?
I was at an event over the holidays and was asked what I do for a living. I mentioned healthcare and, as often happens, immediately heard a story of a medical mishap. When I worked for General Motors in the mid 90s, I almost hated saying I worked for them, because I’d always hear complaints about people’s bad cars (experiences often well remembered from the 1970s or 80s).
So, anyway, a guy told me that his wife was supposed to have a non-cancerous fibroid tumor removed from one breast. This was at an academic medical center with a “top notch surgeon.” His wife came home and realized, to her horror, that they had cut into the WRONG BREAST.
It turns out they removed something from the wrong breast and never cut into the one she had signed off on. The fibroid tumor remained.
She called the surgeon on it and he wouldn’t admit to making any error. He said something like, “We took out what looked bad to us,” refusing to acknowledge or explain why the “correct breast” wasn’t cut into.
At least the Southwest pilot admitted the error:
“I’m sorry, ladies and gentlemen. We landed at the wrong airport.”
Back to the medical mistake… I asked the guy if his wife (she wasn’t there with us) was going to go back and get the fibroid removed. She shouldn’t have to pay for the second “correct” surgery and she probably shouldn’t have to pay (in my mind) for the one done wrong, even if something was legitimately taken out of her body.
He said, “No, she’s traumatized by the whole thing and since they say it’s not cancerous, she’s in no rush to get it out.”
How do these errors occur? There are 50 wrong-site surgeries per week in the United States. It’s not “bad surgeons,” per se — it’s bad systems and bad processes. Exactly the type of problems that lead to a plane landing at the wrong airport. Except, that airplane is very visible and embarrassing. Cutting in the the wrong side of the patient’s body… not so much. And life goes on…
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.