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By January 15, 2014 5 Comments Read More →

Two Recent Wrong-Site Landings & Many Wrong-Side Surgeries

Screen Shot 2014 01 13 at 6.14.40 AM 150x150 Two Recent Wrong Site Landings & Many Wrong Side Surgeries leanIn 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:

Southwest flight lands at wrong Branson airport

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…


mark graban lean blog Two Recent Wrong Site Landings & Many Wrong Side Surgeries leanAbout 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.

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5 Comments on "Two Recent Wrong-Site Landings & Many Wrong-Side Surgeries"

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  1. The recent wrong airport incidents reminded me that a while back a passenger jet flew hundreds of miles past the Midwestern airport where it was supposed to land. Turns out, the two pilots were on their laptops and didn’t notice the error. I wonder if such “distracted flying” was involved in the latest incidents.

  2. There’s nothing new here Mark. Flawed humans operating in a complex system, will make mistakes. Simple answers such as, “If they had been flying on instruments, it would have taken them straight in (to the right airport),” short circuit the kind of thoughtful investigation that you suggest will allow us to better understand the system (5 Whys).

    Any journalist that refers to Mary Schiavo as an aviation expert is simply being lazy. If you were to ask John Nance, Key Dismukes, Tony Ciavarelli, Sidney Dekker, et al, I suspect you’d get a far more cautious statement like, “We’re going to need to listen to the cockpit recordings, the ATC recordings, and review the route of flight to get a better understanding of what went wrong.” Remember that Schiavo (an attorney) makes her living litigating against airlines. Just as is true in healthcare, lawyers impede the work of those of us who really want to improve the system.

    That investigation would look at subtle nuances that make this situation interesting. For example, this is one of very few airports in the U.S. where the IATA code (the one that your ticket lists, like DFW) is different from the ICAO code (the one that you program into the computer, KDFW). At Branson they are IATA: BKG, ICAO: KBBG. Was there confusion about which airport to put into the box? We don’t know, but if they put in KPLK, then the computer is what led them to the wrong airport. The computers that we use in commercial aircraft are circa x86, and there is no autocorrect. Garbage in, garbage out.

    I could go on and on about all of the misinformation in these articles, but let’s talk about healthcare.

    The surgeon who refuses to acknowledge the error isn’t the problem. The system that allows him to deny the error is the problem. Pilots aren’t any more humble than physicians (or nurses, PAs, etc). The difference is that from day one in flight training you debrief every flight, and your errors are detailed with probable causation and available training and countermeasures. There is also a Just Culture system, albeit deeply flawed, that encourages pilots to disclose what happened. This limits “blame” and punitive measures, in a tradeoff for real learning.
    When I say deeply flawed, the Minneapolis incident is a great example. The only reason we know that the pilots were “distracted” is because they wrote it up (under ASAP, the Just Culture system). The FAA, in their rush to please the public and show the world that they’re doing something about safety, abrogated the pilots’ immunity from prosecution. Any wonder why a majority of US aviation operated with suspended ASAP programs a few years ago? If you ask people to trust the system and then publicly pillory them and suspend their licenses with information that you gleaned from that same system, they’re going to walk away from the system. The thoughtful response to this incident came from Key Dismukes, “I’m surprised it hasn’t happened before.”

    One final note on the MSP incident, it was a safety system that made that day a very successful failure (no bent metal, no injuries, 15 minutes late, and a few misconnects). Because of Crew Resource Management, it was expected that when the flight attendant sensed something possibly amiss, she questioned the pilots. They uttered the obligatory expletives and turned the aircraft around.
    Tinkering with complex systems by making simple fixes exposes a profound ignorance of their safe operation. Once again, a responsible and humble investigation is the right path to gain true understanding.

  3. Hi,
    Just my five cents:
    Having been a professional pilot myself and having been responsible for aviation safety and incident/accident investigations, I do agree fully with Steven! In the cases mentioned, a full investigation will be held and, next to the “big” cause (whatever it may be), the report will mention all found causes and circumstances. Of course, to do this properly, it takes time and that is something newspaper journalists don’t (want to) have! Once the report will be available (to everyone interested!), there is no more “news value”. So it is common practice to be “the first” to give an “expert” opinion. However, once the official report is out and other causes of an incident or accident are found, the same “experts” are nowhere to be seen or heard…
    Who was it again who said: “if somebody makes a mistake, it is because the system allows it”? In this case, as in most aviation cases, I am pretty sure that there is more than one “reason” this happened. All we can do at this point is speculate, guess, … The big advantage of the aviation safety environment is that all incident/accident reports are available to anyone so everybody can learn from it and improve (and avoid making the same “mistake”).
    Greetz,

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