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Content ArticleFatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
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Content ArticleThe theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
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Content ArticleThis issue of Hindsight concerns ‘the new reality’ that we are facing. It includes a wide variety of articles from frontline staff and specialists in safety, human factors, psychology, aeromedical, and human and organisational performance in aviation. There are also insights from healthcare, shipping, rail, community development and psychotherapy.
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Content ArticleThis issue of Hindsight is on the theme of digitalisation and human performance. It includes a wide variety of articles from frontline staff and specialists in technology, change, safety, human factors, and human and organisational performance in aviation. There are also insights from healthcare and pharmaceutical manufacturing. The articles reflect the possibilities for digitalisation and human performance, and the challenges for individuals, teams, organisations, regulators, industries, and societies.
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Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content Article
Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this.- Posted
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- Safety culture
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Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content ArticleHigh Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. The authors of this study introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. The authors explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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Content ArticleThe aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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- Medicine - Cardiology
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Content ArticleThe COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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- Surgery - General
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Content ArticleMandatory and voluntary safety reporting policies are an extremely important part of providing guidance for safety reporting in aviation safety management systems (SMS). This blog highlights the purpose of safety reporting policies, how to train employees on voluntary vs mandatory reporting, and how to encourage mandatory and voluntary safety reporting. Although written for the aviation industry, many of the principles can be applied to healthcare.
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Content ArticleOn 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable. ‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries. This Nimrod XV230 tragedy is so rich in lessons, Martin Anderson, Chartered Human Factors Professional, shares on his website a series of articles about the Nimrod XV230.
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Content Article
SKYbrary: Safety occurrence reporting (2 October 2020)
Becky T posted an article in Implementation of improvements
This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware. Although for the aviation industry, some of the principles can be applied to healthcare.- Posted
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Content ArticleRecently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
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Content Article'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
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Event
Human Factors in accident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. Lisa Fitzsimons will talk about common themes relating to human performance and organisational factors which emerge when investigating the technical aspects of an air accident, drawing upon several recent examples. Becky Charles will discuss track worker safety and specifically about an incident which occurred at Margam, UK in July 2019 where two trackworkers were struck and fatally injured. Register- Posted
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Content ArticleThe Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
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Content ArticleIn this article in the Irish Times, Niall discusses his book, Oops! Why Things Go Wrong, and explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, and most importantly, what we can do about it. You can also listen to an interview with Niall on BBC Radio Ulster’s Talkback (Listen from 38 mins to 57 mins). Related reading on the hub: Oops! Why things go wrong – a blog by Niall Downey
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Content ArticleIt has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.
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- Human error
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Content ArticlePoorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimised design. In this study, Pruitt et al. reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety.
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- Human factors
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Content Article"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring.
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- Human error
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Content ArticleOur heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it.
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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EventuntilThis free webinar will explore near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. It will start with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. At this event, you’ll: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems. Who will this be of interest to? This webinar will be of interest to anyone involved in the management of safety events in their industry/ organisation, and especially human factors practitioners, safety investigators, policy leads and regulators. Register
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