After the Second World War, the commercial aviation industry started to take flight. As more and more people flew, the industry started looking at how to make it safer.
Captain Steven Khoo, a pilot for over 40 years with Singapore Airlines and human factors expert, shares how safety evolved in the aviation industry and what healthcare can learn from an industry with one of the best safety standards in the world, at a talk organised by SingHealth Office of Risk Services on 14 February 2017.
"We are at the safest period in aviation history," said Captain Steven Khoo. An oft-cited statistic says that you are more likely to get into an accident in a car on your way to the airport, than in a commercial flight. According to figures from the International Civil Aviation Organisation (ICAO), there were around 33,000,000 airline departures in 2015, and only 6 fatal accidents.
How did aviation become so safe?
Technology and human factor
After the Second World War, the commercial aviation industry started to take flight. As more and more people flew, the industry started looking at how to make it safer.
Their first focus was on improving safety through engineering. This brought about the birth of essential technologies used in modern airplanes, such as the autopilot system, the traffic collision avoidance system (TCAS) that reduces the risk of mid-air collisions, enhanced ground proximity warning system and GPS-based navigation system.
"But after all these engineering improvements," said Captain Khoo, "Fatalities still happened – in what we in the industry call the 'infamous crew resource management' (CRM) accidents." One such accident is the 1977 Tenerife airport disaster, where two Boeing-747 jets collided on the runway, killing 583 people and making it the deadliest accident in aviation history. Investigations pointed to lack of communication, situational awareness and teamwork as major factors that led to the accident.
The aviation industry shifted its safety focus to human factors, as it realised that human error underlies many accidents.
"The level of training provided need to be so good that when the obvious happens, everything runs automatically and we don't need to refer to manuals."
The main human factors concept used in aviation is the SHELL Model, which examines the interactions between the personnel and the Software (rules, standard operating procedures, checklists), the Hardware (aircraft, equipment, technology), the Environment (airspace, weather, employing organisation) and the Liveware (ground crew, flight crew, other pilots).
Airlines started training their crew to overcome problems that may arise from these interactions and conducted annual assessment of their crew's non-technical skills.
According to Captain Khoo, "The level of training provided need to be so good that when the obvious happens, everything runs automatically and we don't need to refer to manuals. Then we can spare our brain capacity to think about out of the box solutions."
Safety culture
In the mid-1990s, the aviation industry started to recognise that an organisation's culture and commitment play a part in safety outcomes.
"You can put barrier after barrier to prevent errors, but accidents will still happen unless you change the organisation's culture to where people do the right thing even when no one is watching," said Captain Khoo
The industry took a proactive approach by creating a system that allows crew to easily report potential hazards in day-to-day operations – through paper and online reports to whatsapp messages and phone calls – and act upon them within 24 hours. When it involves other members of the staff, a confidential report can be submitted. It created a climate where staff want to and are always ready to report errors and near misses.
"The challenge is to create an atmosphere of trust, where your staff knows they won't be punished for reporting a mistake."
Captain Khoo warned, "The challenge is to create an atmosphere of trust, where your staff knows they won't be punished for reporting a mistake."
The organisation also needs to allow a safety culture to take place and commit to it. For example, for a long flight a pilot needs to be well-rested, so the airline management allows periodic naps. If there are violations of safety procedures, the organisation has to be willing to work backwards and examine the factors that lead up to it.
The lessons
Aviation and healthcare are both industries that are focused safety and operate in dynamic and complex environments.
All in all, the lessons healthcare can glean from aviation's safety journey are:
On the sharp end we need to focus on the humans: we cannot eliminate human error, and human performance has its limitations. The organisation thus needs to focus on human behavior for teamwork and invest in human factors knowledge and training.
"I can sleep soundly at night because I know my co-pilots and crew will always do the right thing."
On the back end, the organisation need to instill a safety culture, make the system resilient to errors, and constantly improve safety through technology, research, reviewing standard operations, training and regulation.
Captain Khoo ended by highlighting how important it is to have a safety culture throughout the organisation: "I can sleep soundly at night because I know my co-pilots and crew will always do the right thing. The management has a good night's sleep too, because they don't need to watch each and every pilot's every move."
