A Lean Guy Reads the Globe and Mail – Shoelaces & Plane Crashes
I was in Canada a few weeks back and two articles from the Globe and Mail newspaper caught my eye – stories from England and Russia.
The first was what could be considered a lighthearted story about the excesses of a Prince. There's a better online article from Glamour magazine that includes this tidbit about Prince Charles about his clothing valets (he has three of them):
A valet's other duties include ironing the Prince's shoelaces whenever his shoes are taken off.
Maybe I am fashion-impaired, but that sounds like the “waste of overprocessing to me.” Then again, I guess the royal family isn't under much pressure to reduce wasted motion amongst their staff.
The next story is much more serious…
You might have heard about the Russian plane crash in September that claimed 44 lives, including the entire Lokomotiv Yaroslavl hockey team (including former Detroit Red Wing Brad McCrimmon, who I cheered for years ago.
The article, “Plane crash that killed Russian hockey team blamed on pilot error,” maybe should have had the phrase “management error” in the headline, actually.
From the piece:
A Russian jet crash that killed 44 people, including an entire professional ice hockey team, was caused by pilot error, investigators said Wednesday, putting the blame on poor training and safety standards.
End of story – bad pilot… he's dead, it's a tragedy, but that bad pilot won't harm anybody again. But wait… poor training… poor safety standards… that's not all the pilot's fault, right? There's more to the story:
Alexei Morozov, who led the investigation, said the crew still had enough time to abort the takeoff safely at the moment when they realized that it had gone wrong.
He blamed the plane's owner, Yak-Servis, for failing to observe safety standards and adequately train the crew.
You can blame the crew for not aborting the takeoff (bad pilot!!!) or maybe the owner has some responsibility for the system… including what sound like some glaring problems with management and culture — (the online version of the Globe and Mail piece is shorter, so I'll now reference this ESPN article with the same content):
…one possible reason the pilot obstinately still tried to take off was a fear of reprisals from his employer.
Industry experts say when Russian crews abort takeoffs, make second runs or divert their planes to other airports they can risk losing their bonuses or face other sanctions as carriers focus on cutting costs.
“Many pilots say that those who cause delays in flight schedules … run into various problems at many carriers,” Morozov told a news conference. “Company management doesn't like it.”
If the pilot feared for his job or feared for his financial wellbeing, it's understandable how the system would drive him to take risks. Yet the headlines scream “pilot error.”
There are some training issues or complications caused by the pilots flying an unfamiliar plane:
Morozov said both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like most other Russian and Western planes now, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part.
But instead of putting their heels on the cockpit floor as regulations require, one or both of the pilots left their feet resting on the pedals in line with old habits, inadvertently activating the brakes and slowing the plane down on takeoff.
At first they didn't notice the brakes were on, and then they made the fatal mistake of failing to halt the takeoff, he said.
“A properly trained pilot would have immediately aborted the takeoff when he saw the nose failing to lift,” said Ruben Yesayan, a highly decorated test pilot who took part in the probe. “The plane would simply have rolled past the runway and everyone would have been safe.”
As if those system problems aren't bad enough, it sounds like there were some cockpit dynamics of the type the aviation industry (and some in healthcare) are trying to drive out through the practice of “Crew Resource Management,” or CRM:
A clash of egos could also have been a factor, Morozov said, noting that the second pilot felt like the real leader.
The article points to the fact that one pilot was taking a medication that was not allowed for pilots… so again, easy to pin the blame on bad pilots and “pilot error?” Big huge headline – PILOT ERROR. Details of the article – it's largely the system. Hardly seems fair, does it?
The piece ends with an indictment of the Russian airlines for “widespread neglect of safety in the pursuit of profits.” Unless they fix those problems, it seems that another air disaster is just waiting to happen.
As we work to improve healthcare quality and safety, what are some parallels or lessons learned that you would draw from this tragedy? How can similar errors be prevented in healthcare?