Wednesday, April 10, 2013

Learning from the un-checked checklist

As long as we are on the issue of cognitive errors, it is instructive to review the crash of an MQ-9 Reaper in an unpopulated area in Nevada on Dec. 5, 2012.  The U. S. Air Force Air Combat Command recently published a full report of the incident, noting, "The aircraft, one inert Guided Bomb Unit, a Hellfire training missile, a Mission Kit, and one M299 missile rail were destroyed. The loss is valued at approximately $9.6 million.  There were no injuries or damage to other government or private property."

A summary:

The Accident Investigation Board President therefore found by clear and convincing evidence that the causes of the mishap were:

1) prior to the flight, the throttle-quadrant settings were improperly configured during the reconfiguration of the GCS from MQ-1 to MQ-9 operations

2) this throttle change went unrecognized because the mishap pilot did not personally execute the checklists on his control rack prior to gaining control of the aircraft, and

3) the pilot stalled the aircraft due to an unrecognized, commanded reverse-thrust condition that existed whenever the pilot's throttle was at any position except fully forward.

Additionally, the AAIB found by a preponderance of evidence that the mishap pilot failed to execute his GCS preflight in accordance with technical order procedures, substantially contributing to the mishap.

How many hospitals would publish such a report for the world to see?


Pat Thomas said...

No Paul, not many hospitals and doctors would publish this type of report. Unfortunately, this is why they have malpractice attorneys. I don't know which came 1st: Lack of publicly reported investigations or malpractice attorneys.

I do personally know that FTA aviation accident reports are a critical part of new pilot training. Some pilots memorize FTA report findings to improve their own performance.

Anonymous said...

I agree with Pat; there will have to be some sort of immunity granted similar to that given to other peer review functions in order for this to become SOP. Also, the sheer volume of medical errors and the lack of a centralized mechanism and format for reporting is a barrier.
There is no question that our profession, including the administrative side, is missing a giant learning opportunity, for cultural, legal and structural reasons. We need an overarching vision for how to do this (Paul?) and to set about systematically eliminating these barriers so that learning can accelerate by leaps and bounds. Not to mention to also stop killing people.

nonlocal MD

mark said...

Agree with both, but we in the medical profession and hospital administrations have kept medical errors and unexpected outcomes in the shadows like dirty secrets Current education encouraging the admission of errors with an apology to patients has not been well received. The recent shake up at the Mass Board of Registration might help to shed some light on the previously clandestine system of peer review. Yes, perhaps some sort of immunity so that our patients can enjoy the same assurance of safety control in the OR that they have in a plane.