Ep 2 - Aviation Parallels to the Elaine Bromiley Case
Elaine Bromiley
A healthy 37 year old woman who died after a Can’t Intubate, Can’t Oxygenate (CICO) scenario
Martin Bromiley
The impetus for this podcast was that her husband, Martin Bromiley, a UK airline pilot, commissioned an independent investigation into the circumstances of his wife’s death and then anonymized and published the report so others could learn from it.
Human factors in medicine
As Captain Bromiley put it, this was not an individual failure. It was a system failure. It was a failure of human performance. And he pointed out that in aviation, 75% of airline accidents are due to human factors rather than mechanical failure. We don't know the number in medicine. Is it 75%? Is it more like 80%? Is it 40%? As he says, the number is irrelevant. it's a significant number of people that are affected every day by medical error. And a lot of those are due to human factors regardless of what the number is. And if in medicine, we were to wake up to human factors, we could save many lives.
Aviation accident investigation
Independent investigation board that determines the causes and contributing factors of aviation accidents in a non-punitive manner. It then anonymizes and publishes the report, which includes recommendations for pilots, flight training, training of other aviation professionals, air traffic services, airframe and engine manufacturers, and regulators.
Eastern Airlines Flight 401 (1972)
Fixation-induced loss of situational awareness.
Troubleshooting a landing gear light indicator problem in the cockpit (one of the landing gear lights would not indicate the gear was down and locked).
The autopilot was engaged and the aircraft was flying over unlit terrain (the Florida everglades) at night.
One of the flight crew inadvertently bumped the control column which disengaged the autopilot.
Despite an altitude alert chime being audible on the Cockpit Voice Recorder (CVR), none of the crew responded to it.
The aircraft slowly descended and impacted terrain.
None of the crew realized until it was too late, due to being fixated on troubleshooting the landing gear indicator light.
The landing gear was in fact down and locked and the failure of a single light bulb resulted in many fatalities.
Commonalities between EA401 and the Elaine Bromiley case
Failures of leadership and communication lead to a loss of situational awareness.
These resulted from fixation
in the case of EA401, the landing gear light assembly
in the case of Elaine Bromiley, intubation over front of neck access
Both had moments where clearly audible alerts were not perceived that if attended to would have averted disaster
EA401: the altitude alert chime
Elaine Bromiley: the nurse announcing the presence of the kit for front of neck access in the OR.
The depth of inquiry of aviation accident investigation
Modern aviation accident investigation is not satisfied with finding the proximate cause.
While the board is empaneled, they will look into all aspects of the crash to determine whether things can be improved, whether or not that specific aspect played a significant role in the accident.
For example, if there was a fire, they will analyze the material’s inflammability to determine whether a less flammable material would have helped.
United Airlines Flight 173 (1978)
Fixation-induced loss of situational awareness leading to fuel exhaustion and crashing in Portland
Troubleshooting a landing gear light indication problem, similar to Eastern Airlines Flight 401
Again the light failed to indicate, but the gear was later found to be in a safe position
This time the Captain continued to circle to try to troubleshoot the problem and optimize the conditions for the emergency landing with a potentially unsafe landing gear.
Despite the First Officer (FO) and Flight Engineer (FE) attempting to tell the Captain that the aircraft was dangerously low on fuel, the Captain continued to take time to work the landing gear problem.
When the engines began to fail, the Captain was surprised that it was because of a lack of fuel.
The Captain’s actions in avoiding two apartment building on the crash landing saved many lives.
Commonalities between UA173 and Elaine Bromiley
Fixation-induced loss of situational awareness
UA173 - fixated on the landing gear light
Elaine Bromiley - fixated on intubation
Fixation led to an inability to perceive information
Captain was surprised that the aircraft ran out of fuel
Lack of assertiveness of junior members of the team
Lack of listening to other team members from the leader(s)
Air Florida Flight 90 (1982)
Poor crew coordination and lack of assertiveness / failure of leadership leading to a crash on departure in icing conditions.
Challenge and response checklist: one person reads a challenge (“Engine anti-ice”) and the other person actions the item (move the switch or confirms it is in the correct position) and calls out (“On”). If an incorrect response is given, the person who performed the challenge calls for a correction.
In this case, the challenge was “Engine Anti-Ice”
The response was “Off”
And it should’ve been corrected to “On”
The failure to engage the engine anti ice later led to a false indication in the cockpit instruments showing that the engines were developing sufficient thrust for takeoff when they weren’t.
The Captain ignored the First Officer’s repeated concerns about the amount of ice on the wings and whether the engines were developing sufficient power on takeoff.
Commonalities between AF90 and Elaine Bromiley
Lack of assertiveness
AF90: FO tried to tell the Captain he was uncomfortable with the takeoff
Elaine Bromiley: nurses later said they knew exactly what needed to happen (front of neck access) but didn’t have the language to properly express themselves
AF90 shows that pilots would rather risk death than countermand the Captain. This provides some insight into the severity of the problem of junior members of the team asserting themselves. They need the tools, but also the institutions they work for need to support them in doing so.
Closed-loop communication in medicine
When being asked to perform safety critical interventions (e.g. give a medication, manage an airway etc), repeat back the key parts of what was said and wait for confirmation that it was understood correctly
Example:
Doctor: “Give 10 units of insulin R subcutaneously now and let me know when it’s been given”
Nurse: “Give 10 units of insulin R subcu now”
Doctor: “Correct, thanks”
Nurse: “The insulin has been given”
Doctor: “Great, thank you”
Safety Intervention worth mentioning
Pulse Oximeters invented by Dr. Takuo Aoyagi of Japan. Somehow the idea of measuring oxygen saturation was almost lost to time, yet Dr. Ayoagi persisted and all modern pulse oximeters are based on his initial design.
It’s hard to believe that the physiologic principles were discovered in 1935 in Germany by Prof Karl Matthes but that the first pulse oximeter wasn’t constructed until 1972 by Dr. Aoyagi and wasn’t adopted as the standard of care in anesthesia until the late 1980’s!
Other resources
Elaine Bromiley
Fixation-Induced Loss of Situational Awareness - the case of Eastern Airline Flight 401 on December 29, 1972 (Lockheed L1011) - Mayday episode Fatal Distraction - S05E09
United Airlines Flight 173 - JFK to Portland International - Dec 28, 1978 (six years later, almost to the day) - DC-8 - fuel exhaustion while troubleshooting a landing gear problem - Mayday Focused on Failure S12E08 (YouTube)
Air Florida Flight 90 - January 13, 1982 - B737-222 stalled due to icing on departure and crashed into the Potomac River (74 fatalities including 4 ground fatalities, 4 survivors) Mayday Disaster on the Potomac - S13E04 (YouTube)ACCRAC Ep 325: The WISH Inventory and Well-Being in Anesthesiology with Drs. Higgins and Vinson (anesthesiologists take an outsized sense of responsibility for outcomes - at 5 min)
Random recommendations
See You in Court (CBC Podcast about landmark legal cases in Canada)
Next Episode: Crew Resource Management in Aviation with Captain Mike Schuster