Checklists

March 2nd, 2010

Do you know this story about checklists? Forgive if you do . . . but I didn’t. It comes from Dr. Atul Gawande, writing in the December 10, 2007 New Yorker magazine, and author of the recently published book  THE CHECKLIST MANEFESTO * GETTING THINGS DONE RIGHT.

It seems that in 1935 at Wright Airfield in Dayton, Ohio, the Army staged a fly-off to select the next generation long-range bomber for the U.S. military. Manufacturers Martin, Douglas, and Boeing all had entries in the contest, though it was widely expected that Boeing’s model 299 would trounce the competition; it could carry five times the number of bombs, and fly farther and faster than requested.

However, as the four-engine, gleaming-aluminum-alloy behemoth climbed through three hundred feet it stalled, rolled over, and crashed. Never before had a pilot been required to manage that level of complexity; multiple engines, retractable landing gear, wing flaps, electric trim, and hydraulic props controls. A full plate for one guy.

So the pilot, Major Ployer P. Hill was posthumously forgiven. He had forgotten to remove the elevator/rudder gust lock. As a result the aircraft was deemed “to much airplane for one man to fly,” and thus began the age of the checklist and multi-pilot crews. From that point forward The flying Fortress went on to log 1.8 million miles without an accident.

Dr. Gawande ruefully concludes that, “Medicine today has entered the B-17 phase. Substantial parts of what hospitals do—most notably, intensive care —are now too complex for clinicians to carry them out reliably from memory alone .  I.C.U. life support has become too much medicine for one person to fly.”

Stick with those basics folks! What we have been doing for the past 75 years still works. Zero fatalities on a major since 2001.

Protected: Toyota and the Airline Cockpit

February 19th, 2010

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Introducing Lt Col Chris Hallman

February 16th, 2010

Folks, I’m happy to finally bring Lt Col Hallman into the fray.  Chris served as director of CRM training at Delta before leaving to start his own business, Great Circle Consulting.  He introduces himself in the following way:

Art has made some great points in his blog about the importance of mandatory CRM training and the contribution that training has made to a culture of safety in aviation.  That safety culture pays dividends to crew and passengers alike each and every day, and other organizations, such as healthcare, recognize that.  I’ll take the opportunity, with this entry, to build on the foundation he’s made. 

 

I’m frequently reminded that our proficiency in applying CRM skills is a perishable commodity.  If we don’t exercise those skills as a way of conducting business we lose proficiency.  That’s also why I believe so strongly in a CRM training program that is updated each year in annual refresher training–one that is delivered not only in a dedicated CRM “class,” but incorporated into all phases of the training curriculum.

 

Crewmembers should see human factors elements in systems training, simulator and aircraft training and line checks.  That’s why Line Oriented Flight Training (LOFT) and Line Oriented Evaluation (LOE for those in an Advanced Qualification Program) is so critical.  LOFT or LOE provide the opportunity for those in training to put all their skills together in realistic simulations that test the pilot in the full range of skills required in line operations.

 

CRM isn’t some special set of skills that we apply only in certain circumstances.  Those skills must be tightly woven into our technical skills and applied with the same diligence that we devote to our stick and rudder skills.  The NTSB’s recent release of its findings in the Colgan Air accident near Buffalo provides a sobering reminder of how a series of technical and CRM failures can lead to tragic consequences. 

 

Effective training programs consider CRM and technical skills as equal partners in developing a well-trained flight crewmember.  In my next entry, I’ll talk a little about the importance of a well-calibrated instructor team in ensuring the overall quality of the training program.

Protected: Christmas blessing.

January 18th, 2010

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An Enviable Safety Culture

December 5th, 2009

I am speaking today at a medical leadership summit in Boston because they are interested to know more about the successful implementation of CRM in the airline industry.  The underlying theme I emphasize emphatically is that we exist within An Enviable Safety Culture; that safety drives every decision we make.

Not so in medicine.  While the major airlines haven’t experienced a single fatality since the fall of 2001, there are more than 100,000 deaths due to medical error in the U.S. every year!  Do the math:  100,000 deaths ÷365 days=274 deaths per day, 24/27, 365.  That is two fully loaded 737scrashing every day . . . one every twelve hours.

The corresponding truth is that medicine is infinitely more complex.  Yet there is much they can learn from us and there are dedicated efforts underway to adapt CRM concepts into the everyday practice of medicine.  In fact our good friend and CRM pioneer, Dr. Robert Helmreich at UT Austin is very instrumental in providing the analysis and insight necessary to develop meaningful training regimes in the various medical disciplines.  Also physician and professor Dr. Lucian Leape, at Harvard School of Public Health has devoted decades to researching and campaigning for programs to substantially reduce the incidence of error in medical practices.

For instance Dr. Leape is quick to note that most hospitals don’t even have a dedicate safety program in place.  “They have not made safety the priority it has to be to make safe health care a reality.” I remember a certain airline that didn’t have a safety department in the late 1980s.  I can only think of one accident occurring since the department was created and that was due to an uncontained engine failure attributed to the manufacturer.   Hmmmm.

I am honored to have this opportunity to sing our song and I will have a great deal more to say about the parallels in our industries in the days to come.

The genesis of mandatory CRM training.

December 3rd, 2009

Welcome back. For those of you who can’t remember the genesis of mandatory CRM training, unless you remember hearing about it in your kindergarten or in the neo-natal ward, here are the cliff notes.

CRM got the final push one clear cold night in December of 1978 when a United DC-8 approaching Portland, Oregon, experienced a landing-gear-indicator anomaly as they configured for landing. So they broke off the approach and entered a lazy VFR hold over Portland while the troubleshot the problem; no red or amber gear light, but no green one either. Good on ‘um that far at least.

However, the problem was that the captain totally fixated on the landing gear issue to the exclusion of everything else. Even when the S/O advised him of their low fuel state he simply couldn’t hear it. The simple truth is that the captain dithered until they flamed-out all four engines and drifted down into an empty field east of the airport. Almost all of the passengers survived. Unfortunately, the flight engineer, the guy who couldn’t get the captain’s attention, perished.

I’ll bet that seems inexplicable to most of you younger folks. We have a much more collegial and interactive cockpit today. And there is also a point worth making that good CRM isn’t always pretty. With a captain’s brain “up and locked,” as it was in Portland, I’m guessing that you copilots would have done whatever was necessary to get his attention, right? Wasn’t always so . . . but we’ve come a long way baby.

From that point forward the airlines were required to create and conduct CRM training programs. And though no two programs are the same, they all seem to have had the desired effect. Ten years after the Portland accident Captain Al Haines masterfully orchestrated a miraculous outcome in Sioux City. He attributed much of the crew’s success to the United CRL program. And most recently, Sulley also has credited similar training in his background for the remarkable team performance last January.

Keep the shiny side down and the communication flowing.

Thanks for checking in.

December 3rd, 2009

Thanks for checking in. I want to begin my life in the blogosphere with a tribute to all of you out there packin’ the mail day-in and day-out. Your safety performance is unparalleled in any industry. And a special thanks to Captain C.B. Sullenberger for making us all look good. Bravo Zulu Sulley! (And hey, did you really grab the WSJ out of a seat pocket when you went back in for a second look?)

Though I’m not quite Grandpa Pettibone, my experience does date back to the pre-CRM era. Some of you may recall that back then we planted a DC-10 in Mexico City one night when all indications were that the copilot allowed the captain to land on the wrong runway out of spite. And remember Tenerife? That KLM captain just wouldn’t listen to the S/O’s concern about Pan Am on the runway. Many died as a result of those barriers to communication.

We need to continue breaking those barriers, and I’ll be joined in discussing those critical issues by Colonel Chris Hallman, former head of CRM training at a certain airline and C-130 driver for a certain military organization. Chris now heads his own consulting firm where he provides this sort of training across cultures. He and I probably won’t agree on everything because he is a lot smarter and younger than I am. But hey, as they used to tell me at a certain airline, I will never be totally useless because I can always be used as a bad example.

Stay tuned.

Arthur K. Samsom

It has been said that CRM is just plain ol' common sense . . . but it sure is amazing how little common sense we have some times.

 
Good communication is as stimulating as black coffee and just as hard to sleep after. - Anne Morrow Lindbergh