Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Niall Downey. Quite the experience. A former surgeon who then became an airline captain who’s author of books in this space. Great experience, great stories. Niall, welcome to the show. Very excited to have you with me.  

Thank you, Eric. It’s great to be on the podcast. I’m a big fan of it.

Now, first we have to start surgeon. It’s a credible profession. You spend years becoming a surgeon. How do you go from being a surgeon to becoming a pilot?

Well, I trained as a doctor in Trinity College in Dublin, in Ireland. So that was a six-year course. And then I subsequently trained then as a surgeon between Dublin and Belfast. So, I got my fellowship with the Royal College of Surgeons in Ireland when I was in Belfast and subspecialised then into cardiothoracic surgery, so hearts and lungs. I then moved back to the National Cardiac Unit in Dublin in 1998, that would have been then, and spent about a year there. But the way the system was in the ’90s in the UK and Ireland is that you worked… It’s the equivalent to a resident in the States, it’s called the Registrar. But to progress on then to become a consultant or an attending, you had to get what was called a Specialist Registrar Post. So, you call it specialist, trainee. That was actually the exact same job, same hospital, same patients, same money, but it was recognized differently on paper. And unfortunately, if you didn’t get the training job, you had absolutely no chance of progressing. I’d already tried the States at that stage. I’ve been shortlisted in Mass General. But again, they offered to let me work there, but it wouldn’t count as training.

I’d already tried the UK. I’d been in touch with people in Australia. So, there was no problem getting work, but there were no training posts. And then when they shortlisted the post in my hospital in Dublin, I didn’t make the shortlist. So, I read between the lines and realized that I wasn’t being considered there either. So, they were happy to employ me in one of their private hospitals operating on their patients, but not to give me a training post because I It’s such a shortage of them. So, I was such a shortage of them. So, I was left. Basically, I could see my career coming to an end after 12 years of training. And the following Sunday, the Air Lings is had an ad in one of the Sunday papers looking for cadet pilots. I saw that it was all chest in aviation, no background. I saw the ad and thought, right, let’s pursue that.

And so, a life flying around the world followed. 

Well, it started, there was four and a half thousands of us. Excuse my cough, because hay fever. Four and a half thousands of us applied for 30 posts, and I got in number 11. So, then we went off and spent about 14 months training between Oxford in the UK and Arizona in the States and came out the far side then with the professional license. I think it’s then trained me on to the Airbus A320 fleet and been progressing through the system for the last 25 years, basically since that. And I’m now the captain on our A330 fleet. So doing transatlantic flights out of our Manchester base in the UK at the minute.

And so incredible connection because very few people I’ve come across understand that depth of safety in aviation and how safety has gone to where it’s at now. At the same time, on the side of health care, a tremendous opportunity in terms of connecting both. So, tell me a little bit about some of your experience in terms of applying the principles of safety from aviation that are proven, have worked, deliver incredible results to health care. And we should start with your story around the chief exec in the NHS, because I think that was a great introduction to it.

Basically, it was a bit of a culture shock. Was I actually in aviation a couple of years before it really sunk in to me what was going on? It’s a whole different mindset. I think the chief executive story, maybe the one a couple of years ago to start a COVID, I volunteered back into the NHS to go back and work as a doctor because we kept hearing how short staff they were. And after pursuing the local hospital Trust for about six weeks. The fancy told me that they weren’t short of doctors. Thanks for offering. So that’s why I ended up writing the book. I basically had all the spare time in my hands. Sixty flights a month has become one return flight a month to Heathrow. So had to fill the time somehow. So, I started writing the book. And then last year, so a couple of years down the line, I was given a presentation to the chief executive of the trust and the whole C-suite. And I explained at the end of the talk that my book was about to come out and that I volunteered into the trust and had been told that I wasn’t needed.

And it was the first she had heard of it, and she wasn’t impressed.

I’m sure in the height of COVID, that would have been quite an extra pair of hands.

Well, it would have been, at that stage, it was quite a while out of clinical practice, so I wouldn’t have been much use there. But I certainly had things that could contribute.

Tell me a little bit about how you’ve been able to apply the principles from aviation safety into health care.

Basically, the business set up is called Framework Safety Group. And the reason I call it framework is that in aviation, we have a framework that we fall back on. So, if anything goes wrong or even when things are going right, we have a framework approach. So, there’s three big legs to the stool. First leg is our reporting system. In health care, if you make a mistake, it’s generally name, blame, shame, retrain. In aviation, we’ve got it. The just culture means that I can put my hand up and report things without any worry about disciplinary action or any dismissal. That is taken as a genuine mistake. Now, it doesn’t cover gross negligence and it doesn’t cover malicious harm. So, it’s not a get out of jail free card. But if I make a genuine mistake, I can put my hand up, safe and knowledge that I won’t be targeted for it. We then, second leg of the stool then, is we then take a systems approach. So, in health care, the second step is generally who went wrong. In aviation, the approach is what went wrong. So, the logic for them will be, well, you’ve been flying for us for 25 years.

If you were a crab pilot, you’d have made that mistake long before now. So, what happened today? And we look into the system. I’m usually find that there was a trip wire in the system that I fell over. And we try and engineer it out and replace it with a safety net if possible. They try and prevent the same thing happening to a colleague further down the line, which is why we’ve made such progress and health care tends to stagnate because they don’t get to that process. And then the third leg is our crew resource management, our CRM philosophy, which is how we actually manage our earners. And staff are taught that from day one and it’s recurrently trained throughout your career. So that’s the three legs of the framework. And I think that framework is very transferable in two basically any safety critical industry, including health care.

Yeah, I think that’s the part is A lot of the learnings from aviation, phenomenal learnings, they’re transposable in every industry, but not a lift and shift. It’s not exactly the same. It’s adapting. I think the challenge I’ve seen in many industries is this desire that unless it’s been created in my own industry, it doesn’t apply, it won’t work. So how have you been able to broach that? I mean, you have the benefit of understanding health care like few others can, while also have that aviation background.

To be honest, Eric, it’s been a hard sell. I spent 13 years on this now, and it’s only in the last year since the book came out, I’m really starting to get any traction at all. I basically need someone just to buy the concept. Now, at the minute, I’m working for a big private hospital group in Dublin. The chief executive got in touch earlier this year. And by luck, he used to be one of my consultants when I was in cardiac surgery in Dublin. He was a cardiac surgeon up until last year and then also chief executive of the biggest private hospital group in the country. So obviously, we already knew each other from our previous careers. And he’d read the book and he’d heard a few other podcasts had done and read a few articles. And basically, I agree with the concept. I bought the whole idea. He’s asked me to come in and try and apply it across their whole hospital network, which we’re a couple of months into the project now at the minute. So the first step is that you accept that there is room for improvement and that the aviation approach can be transferred.

So that’s been a great start. But generally, it’s very hard to get healthcare to buy the concept.

I think that transposes to a lot of other industries as well, because I think any high-risk, high-reliability industry needs to be constantly looking for best practices. Aviation is one of the few, I think, you can show where there’s been a significant leap, even if you look backwards in the 1960s to how it operates today. Very, very different operating environment. Tell me a little bit about each one of those tools. You talked about just culture, and I’ve had quite a few podcast guests talk about just culture. I think what you share is incredibly important, this element that if you want to be a learning culture, learning environment, you need to have people comfortable raising concerns, raising mistakes, and that’s harder than it looks.

Yeah. And I said just culture is what’s transformed aviation. I think we need to be careful that we don’t get complacent about it. I think the way Boeing have gone for the last few years has been a great example of where it can go wrong. That the just culture In Boeing, it doesn’t seem to have worked for the last 15, 20 years. And it doesn’t have problems quickly. It tends to accumulate over time. I think we’ve seen now recently with, say, the 77 max, and so instance like that, now that These problems have been gradually accumulating. And it’s like the Swiss cheese model. Eventually, you get enough holes of cheese lining up that it starts to cause problems. I think that’s the stage I’ve got to know. I think it’s a great lesson for all of us that just culture is great, and the aviation approach is great, but we need to keep working on it. We can’t get complacent. If you get complacent, it falls apart. So, it’s a progress, a whole evolutionary process that we need to keep moving. If we try and stand still or think we’ve achieved all we need to achieve, it stops and it retreats very quickly.

But then I think the just culture has been the game changer for us. Because you can put your hand up, you can become aware where the problems are. You can’t solve problems if you’re not aware that they’re there. So, the just culture lets us know what the issues are, and then we can start addressing them.

And I think your example, your connection to the Boeing one is an interesting one because even in some of the recent testimony that was heard, the references people are talking about is they didn’t feel comfortable speaking up, raising concerns, which is very much counter to the just culture. Something must have gradually introduced over time where those data points that you want so you can address the system weren’t coming through.

Yeah. So, we have to be careful not to think we’ve achieved all we need to achieve and stuff. We need to constantly keep moving. With the just culture then, because we have the reporting system, and basically the reporting system is shared far and wide. One of the examples I use is the Air France crash back in 2009 when the Airbus A330 crashed into the Atlantic. Our planes have telemetry like Grand Prix cars. So, they send information via satellite. They like live while we’re flying. So, it goes back to the company’s headquarters, so Dublin in my case, and to the factory, so Toulouse for Airbus this case. So, in their case, the black boxes weren’t found for two years, but using the telemetry, they had a rough idea of what had happened, and they managed to put a picture together of what they thought had happened in the accident. So, we were actually training the accident within about three or four weeks of it happening. For a comparison, there’s a study done in Cambridge, in the UK, a few years ago. Into health care, and it shows their reaction time was about 17 years.

Wow.

So, if you like it, we’ve written a paper, and here’s the new gold standard of how to do something. It takes seven years before it’s applied across the coal face, by which stage it’s probably obsolete. Where I say, with the Air France crash, worldwide, all Airbus operators were training the new system within three or four weeks of it happening. And that training has now been incorporated into our current training every six months. So, it’s called the UPRT, Upset Prevention and Recovery Training. We do that now every six months in the simulator. And we’ve been doing that now ever since 2009. And touch wood, so far, we haven’t had the repeat of the Air France crash. 

You just highlighted something I think that’s also… It’s not directly one of the three stools, but I think it’s key that I hear in aviation compared to a lot of other sectors, is this constant simulation, retraining. It’s part of it. In too many industries, what I see is you get qualified, and then you stay qualified for the next 50 years, whether or not you’re capable or not to do it, versus here, you’re constantly going through scenarios, simulations, learning. 

Yeah. Again, that was a tie in with the CRM, but then we’re constantly looking to trap error and avoid trap litigate. So, the training then because the just culture means we can speak up, the reporting system then lets us know where the problems are. And then that information is then found into the training department. So, they then actually construct the simulations around what’s been happening in the industry and around the world so that we can train relevant stuff. And worldwide, we generally have the same aims. They say the World Government Body has identified six big headings of things we need to focus on. One of them, say, being runway incursions, which has been a big issue in the States over the last 6-12 months, even. We had the Japan crash in Tokyo back in January this year, which was down to a runway incursion. Now, we’re aware there’s a problem. It’s been highlighted worldwide. And we have five or six new safety nets built in to try and address that. And it is getting better, but it’s still not perfect. We’re still having accidents. We’re still making mistakes. So again, the idea of the simulation and training is that we put ourselves in the scenario.

Here’s the mistake coming. Or here’s not even necessarily a mistake, just here’s something failing on the airplane. Do you know how to handle it? And again, the framework approach, because in the past, there used to be specific things we would train. So, you knew that were coming up and you revised them, and you turned up at the simulation exam and you knew what to expect and you performed as expected. Then we realized, well, that’s not really very realistic. And that’s what happened in the Air France crash. Something happened that they hadn’t seen before. And then because they hadn’t done it in the elevator, we’re, well, now what? So, it’s in the last 5-6 years now, certainly in Europe, we’ve changed the system. We’re now looking at evidence-based training, EBT. So, we’re now looking at training, again, a framework approach that now, instead of having set scenarios, we’ll have something happen. And even the instructor doesn’t know exactly what the details are. They’ll have a list of scenarios. They’ll pull one out of the envelope and say, Right, this is what’s happening in this one. So, they’re not even aware what’s coming next. So, it means then you can’t go in prepared for it.

And it’s actually improved the training an awful lot. I go in with an overall framework approach. So, here’s how we’re going to address any general problem, and then we’ll fine tune it according to what the actual issue is. And St. Harling’s has been one of the leads in Europe for implementing that, and it’s been very successful. Now, there’s a lot of simulation coming in now in health care as well. And I think that’s a great thing. When I trained it, we see one do one, teach one. I learned to saw chest open by saw chest open. It’s great now that you can actually do it in a simulated low-risk scenario now where you can actually be trained to do it. And if you do it wrong, you can stop and repeat. So, I think that’s one of the big thing’s health care has taken out of aviation so far. Health care means that they are making progress. I just think they could be progressing faster. And there’s a lot of mistakes we’ve made in aviation and in other states of critical industries. And we’d like to share them with them so that they don’t have to make the same mistakes and learn the hard way.

So, you touched a little bit on the Just culture. Love to hear you talk a little bit about the systems view and systemic approach to safety, because I think that’s another big theme to focus on, as well as when you mentioned the Swiss cheese. So, can you elaborate a little bit more in terms of the applicability of some of these concepts?

Yeah, well, the systems approach, again, is the second big leg of the stool. And it’s critical to the way we do things. So, to simplify it right down, instead of looking for who went wrong, we look for what went wrong. In a lot of the health care scenarios, the medication errors have been a big issue for the last decade or so. And from talking to staff, you often find that there was a medication error, they gave the wrong dose or a wrong drug. The investigation, so looked at it and find, let’s say the nurse made an error. She calculated the dose wrong; she gave the wrong one. And it’s not right, okay. So, we’ll retrain the nurse in how to do arithmetic, basically. And that’s a little bit of retraining. And then we send her back out. Now, that’s basically a very simplistic approach of who was the last person to touch the ball and they take the hit on it. In aviation, we look, okay, that person made the mistake. Now, they’ve been here for 15, 20 years. Why did they make that mistake? And then we look and see, right, well, what else was going on?

And you are often I found then that there was a case I was involved in last year. They made a mistake in a hospital. It was investigated and they decided that the nurse had given the wrong dose of the drug. So, the solution was that the nurse now, or all the nurses on the unit, now They have to cross-check certain drugs with one of their colleagues before they’re allowed to give it. And it didn’t really work. When you dug a bit deeper. What actually happened, it’s post-COVID now. A lot of specialist units have lost a lot of their experienced staff. They have less experienced staff now on the They’ve got agency staff coming in who are not used to working in that ward. The experienced staff are trying to mentor them. They may be looking after more patients than they have in the past. They’re missing breaks, they’re missing meals. We all make more mistakes when we’re hungry, angry, late, or tired. You find when you actually look into it a bit deeper, the real reason that the nurse made the mistake that night is that she was too busy. And then you think about then, how was it resolved?

They made her busier. So again, that’s not going to work, and it didn’t work. So, in our case, then we would then look back another few steps. Again, you mentioned the Swiss cheese idea. They found the first hole in the cheese and stopped there. What we need to do then is keep digging back and saying, well, where were the other holes? So, there might be about five layers of the Swiss cheese. Now, getting the nurse to cross-check the drug, grand, there’s one of the holes filled. But what about the other four or five? It might be a lot more efficient to fill those instead. So that’s the whole idea of the systems approach. We work out what went wrong on the night and how can we improve that. And again, if I can even get that across to health care, that will transform it because a lot of staff feel victimized and blamed. When they make a mistake, health care staff are very hard workers. They’re very dedicated. They come to work to do their best. When something goes wrong, it affects the patient, but it also affects the staff member. They’re going home now, that night thinking, well, I injured a patient. 

I’ve had a very bad day at work. You find then the retention rates drop. If you can try and avoid them getting blamed for it, that even if the mistakes still happened, that they’re not held responsible, we work out, well, how can we improve this for everybody? You find that the staff turnover reduces. It’s easier to keep staff there and overall staff satisfaction improves. There’s been studies done that when people are under investigation, that the suicide rates go up as much as fourfold just because they’re being investigated. So called the second victim. So, the system is one big way of addressing that, that we’re not blaming you, we’re blaming the system. Can you help us find out why you went wrong that night? Because it’s obviously not just your fault.

I think it’s a key because I see this across industries. So, it’s not just a health care piece where you go look at the last line of defense, the last hole in the Swiss cheese, and blame that person. It’s the easy one because it’s very complicated to go and understand all the various system factors that came in. But also, to what you just shared, it means that safety is a team sport because now you’re looking at HR. Hr had responsibility even in terms of scheduling, in terms of looking at skills and capabilities that are on shift. It’s starting to extend the role of safety to beyond just the critical staff at the front line.

Yeah, and I would extend it even further. I would extend it out to the patients and to their families as well. The line I use now is that the healthcare is not a spectator sport anymore. The guy did a TED talk in Stormont in Belfast here back in 2016. Part of the idea is that we had to widen the whole idea out that it included patients and staff. So, you might have, and I’m not sure about in the States, but in the UK now, you can have maybe two staff nurses looking after a ward of 30 patients. Their attention is going to be severely distracted. The patients looking after one person themselves. So, if they see something that they think isn’t correct, they should feel comfortable speaking up and saying, I’m not happy with this, or just like, I’ve noticed this. Is that okay? It doesn’t have to be an accusation to the staff member that you’re not doing your job properly. It can just be a help that, I’ve spotted this. I’m not sure that’s correct. Do you want to have a look at it? So, you’re an extra pair of eyes. Family members the same.

So, we talk about crew resource management. We have a very broad definition of crew. From the health care point of view, we see it as all the staff on the wards, the porters, the cleaners, the admin staff, the patients, their families. Everyone has an input. Everyone has an opinion. So, if we bring that opinion to the staff and let them basically benefit from the knowledge that the patient has. And as well, patients all have multiple comorbidities. They know how they interact. Staff member generally doesn’t. Everybody’s slightly different. So, the patient is the best judge themselves of how they feel. And we should encourage them to contribute. They don’t make the final decision, but they’re certainly a partner in the decision making.

Right. Nothing about me without me, as they say here.

This episode of the Safety Guru podcast is brought to you by Propolo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at propulo.com.

I vaguely remember when we talked about you had a stat around the number of prescription errors in the UK.

There was a story in the BMJ years ago. It showed 237 million errors in NHS England, which has 55 million people.

That’s crazy in terms of the volume. And it goes back to you’re never going to save it just based on the last line of defense.

That’s the problem. If you rely on the last line of defense, it’s not going to work. One of the examples I give in my talks is a lot of medication is very similar packaging, very similar labeling, very similar short presentation. And we wonder why people make mistakes at four o’clock in the morning when they’re tired.

Yes. Who wouldn’t make a mistake at four o’clock when you’re tired?

Mistakes are inevitable. That’s how we manage them, the counts.

It’s the same as a pilot with fatigue. It’s going to happen; jet lag is going to happen to So a pilot just like it would to anybody traveling across time zones. But you just don’t want that to be a critical failure.

I miss about two night’s sleep a week. When I fly back from the States, I fly back through the night and land in about six or seven o’clock in the morning. So, I’ve now been up all night. And that happens one or two nights a week. So, there’s an accumulated tiredness there. But we factor that into our decision making. Say when we’re coming in to make an approach into Dublin, like I mentioned to the co-pilot. So, we will do a brief. Here’s how we’re going to get in. Here’s what we’re going to do. And the risks are, right, okay, it’s five in the morning. We’ve been up all night. We’re tired. Keep that in mind. If you see anything you’re not happy with, speak up early. Don’t assume that I spotted it and I know what I’m doing. It might be something I’ve completely missed because I’m tired. But you’re a second, again, bring the patient into it. You’re a second pair of eyes. At least highlight to me that there’s something wrong. It might be something I’m quite happy with but raise the issue with me so I’m aware of it. It’s about sharing mental models.

And that, I think, is a good tie into your… You talked about CRM operating philosophy. Can you tell me a little bit more about some of the principles there and how they would translate to other industries, including health care? 

Well, the CRM can be broken down in different ways. The traditional way we’ve been using for quite a while is six big headings. So, they all overlap, really. But there’s communication, leadership, stress and workload management, then decision making, situation awareness, and threat and error management. So, all research has shown that communication counts for by 70 % of issues or adverse events in all safety critical industries, including health care. So, if we can even focus on that. Now, the communication, it sounds like it’s very easy. It’s actually not. It’s a main field. One of the examples, I play a video to the staff yesterday, same when it was presented. I don’t think you have it in the UK, or in the States, rather. It’s the two Roni’s. Now, there were two UK-based comedians, and they had a sketch show. One of the sketches is that William comes into the hardware shop and ask the man behind the counter for four candles. So, the guy goes and gets four wax candles that you can light to take home with you. And there’s no four candles. He says, Yeah, well, there you go. Four candles. He says, no four candles.

Handles for forks in the garden. He wanted a new handle for his garden fork.

Four I explained in the staff.

So, there’s three stages. There’s the communicator, there’s the message and the receiver. The communicator passed on a very clear message, which the receiver heard because he even read it back, but he misinterpreted it. So, what you think may be a very clear message to a patient. They might actually have interpreted something completely different out of it, despite the fact you’ve given them a very clear message. So, the communication science is dead easy. It’s not. So, in aviation, we have a readback system to try and make sure that we’ve definitely heard it properly. Even then, that can be misunderstood. I can read it back, but I can still interpret it differently. So, if we’re very keen then that we try and get feedback from patients that know, so what do you understand is going to happen today? What are your concerns? And try and work out. Those are the same as the message that’s actually been processed. So, we focus a lot even on the specific terminology. In aviation, in theory, we all use English. Practice is not that simple. If you’re in Spain or France, they’re speaking local language. But what we do is we have a very limited vocabulary.

We reduce the number of words we use, reduce the amount of confusion. We give simple instructions at a time, maybe one or two at a time. We don’t go beyond that. We try and keep it as simple as possible to avoid. So, communication is critical. We actually get trained in communication. Healthcare staff don’t. And also, we’re training… We’re communicating with other people who’ve been trained in communication. Health care staff not only don’t get training, but they’re also dealing with members of the public who haven’t been trained. So, it’s a double jeopardy, really. It makes it twice as hard for them. So, I think that at least if we can train the health care staff, they can try and improve their end of things, that they’re aware of where it can go wrong. And that also reduces the… At least they’re aware then of the possibility of misunderstanding in the other side. They try and reduce communication problems. Now, again, you’ll never resolve it completely. But this is all about trying to improve things, not change things. We’re never going to reach zero harm or zero errors. But there’s certainly room for maneuver. Health Our own research shows that we can reduce the number of adverse events by 70 % by using aviation safety techniques.

But a lot of them are still pretty reluctant to actually use those techniques.

Your point on communication, I think, is really good one because there’s a lot around how much I share in information, the language I use, so you don’t introduce risk by removing or introducing words by choice of words, and also the readback, the checkpoints around, how I communicate, have you understood, and does it match my instructions?

Even a simple word, if you look at the actual vocabulary, one word that we try to avoid is left and… When something is correct, saying that it’s right, because then you get an index, say, one of the examples I use in my book, as I say, somebody goes in to get a kidney removed and they’re getting to say they’re left kidney removed, but they remove the right kidney, but the right kidney is the wrong kidney. So simple words like that. You’re used to write having two different meanings. So again, you’ve opened a risk of misunderstanding. And if you can try and avoid that. So instead of talking about right and wrong, talk about correct and wrong. And again, there’s one of the holes in Swiss cheese filled already. They’re very simple things like that. So, if you’re aware of where they can go wrong. I simplify a lot of my training down to the two comments, basically. Where can this go wrong? And what’s plan B? So, if I’m talking about right and wrong, you can misunderstand what I’m talking about and think right as in right side, when we maybe should be operating on the left side.

So, to avoid me introducing that misunderstanding for you, let’s just not use that word at all. There’s plenty of other words we can use. Correct. Again, it sounds very pedantic, but in aviation, we are quite pedantic about stuff because, again, Yeah, absolutely. If I make a mistake in health care, I can kill a patient. If I make a mistake in aviation, I can kill 300 people and I’m going to be one of them. So, a guy could skin in the game. So, we’re very keen on the terminology we use. We tend to spell things out even phonetically. So, if I’m being cleared to a certain waypoint, we’ve got checkpoints in the sky, they’re motorway junctions, basically. I can be cleared to take a shortcut to one of those junctions. A lot of them sound quite similar. So, we’ll actually spell out the name. If we’re not sure, we’ll spell out the name of them and we’ll spell it out using the alphabet. So, if I say M, that can sound very like N.

Yes, very similar.

So, I’ll talk about Mike or November, which is a lot clearer to understand. So again, we can see where the potential for misunderstanding is. So, then we try and what’s plan B? We resolve that by using the phonetic alphabet when it’s appropriate.

I mean, Tenerife is a great example of miscommunication even and how choice of words can have a significant impact.

Even like Tenerife, again, when you look at it, it was, again, your classic Swiss cheese. There was about six or seven different layers. And if any of them had been addressed, the accident wouldn’t have happened. But from the communication point of view, there was fog, so the tower control couldn’t see the planes. So, you’re relying on the actual words. One of the instructions he gave the KLM was after takeoff, he was told what he was to do next. He was basically given instructions. But the only word the captain and KLM heard then was takeoff. So off he went. So, the terminology has now changed. When I arrive at the runway, I’m not ready for takeoff. I’m ready for departure. And the only time… Again, it’s great. I’ve heard it used. I was in Orlando a couple of weeks ago, and I heard a pilot using the wrong terminology, even 50 years down the line. But I would now arrive, I’m ready for departure. I’ll then be cleared to line up and I’ll be cleared for takeoff. And the only time we should use the word takeoff now is when we’re cleared for takeoff. So, there’s no misunderstanding.

I think this is a very good example, because if I remember in Tenerife, there was also noise on the radio and an intercept, so some words could have been missed as well. And if you hear the word, take off without the context, it could also drive a mistake.

Yeah, what happened there is they got our two-way radio system, I can only carry one voice at a time, or if it tries to carry two, it ends up garbling. So, the man was cleared or given instructions after takeoff, and that’s okay, clear for takeoff. The If Han Am, who’s on their own, may come in towards him, realized, no, hang on, he’s now taken off and we’re coming towards him. So, he actually called the tower. Can you just confirm? Has he taken off? But the tower was also calling back as well because they’d realized there was a misunderstanding. So, they ended up taking over each other. So, nobody heard anything. But again, that’s one of the risks of two-way radio. So again, it’s another hole in the cheese, but at least you’re aware of it.

Yeah, exactly. And I think that mindset around the Swiss cheese forces to think about what could go wrong in all the various elements, not just the last decision.

Because, again, especially in, say, transatlantic, now there’s a lot more traffic. So, we now have a text message system. So, a lot of our communication with air traffic control now is done by text message, which frees up the radio. So, there are less people competing on the radio.

Phenomenal examples of how you can take aviation examples and bring it to health care. But I would say any other industry. All of these principles apply to any other high-risk industry and is, I think, the next leap of performance from a safety standpoint. Tell me a little bit about your book and if somebody wants to pick it up.

The book is called… It’s about errors. So, I thought, what would you call the book about errors? Oops. Why things go wrong? And it’s about understanding and controlling error. So, it’s available in the UK. It’s available in the shops. It’s in Waterstones. It’s in all the independents. In Ireland, it’s in Easton’s and all the independent shops. And in the States, Burns & Noble are carrying it on their website, but not actually carrying it in stock in the shops. It’s available on Amazon as well. And the e-book format has now come out in the last couple of months as well. So, it’s available now on Kindle or Nook for Burns & Noble readers. It’s on Apple Books and various other platforms. So, it’s accessible either in hard copy or an electronic copy.

Thank you. Thank you very much now for joining me today and sharing some of your experience and the connection. I really do encourage a lot of other high risk industries to really look at how can you bring some of the learnings from aviation because there’s been a substantial leap in performance by learning, by creating this just culture where people are comfortable speaking up, by looking at the system, as you mentioned, but also from an operating philosophy, a lot of great learnings there to carry into any industry. And when you mention that in Well, in health care in the UK, there’s a lot of… Sometimes people are saying there’s too many pilots talking to us. To me, that’s a good thing because at least there is that connection. There is a desire to do more. So, tell me a little bit about how that came about in terms of health care starting to look at aviation.

Well, I think they’ve been aware that with someone to contribute for a while, but there was very little input. One person who’s transformed the whole approach is a friend of mine, Captain Martin Bromley. He’s a captain with British Airways in the UK. His wife, Elaine, went in for a routine surgery. I think it’s over 15 years ago now. Elaine was only about 35, and she was just gone in for a routine ENT surgery. And she had an experience team working with her. Two anesthetists were putting her to sleep before she went for the surgery. They tried to intubate her and discovered then that they were having difficulty. It was a difficult airway. And it became, it can’t intubate. And normally there’s procedures for that. There is a plan B. The staff there had a trolley that would allow them to do a tracheostomy, which would basically open a hole in the front of her, in front of her airway, and at least establish air going into her lungs and into her brain, more importantly, which then stabilizes the situation. And you’ve now bought quite a bit of time to actually try and address it.

But fortunately, when someone goes badly wrong, our brain is wired by evolution. Evolution, we’ve been evolving for about 200 million years now. The brain evolves very slowly. Healthcare and say, aviation has evolved very, very quickly in the last 100 years. So, our brains haven’t really caught up. So, we’re doing very complex, very high-tech stuff with a brain that’s running on caveman software. So caveman software is basically you go straight in the fight or flight. It’s the amygdala hijack. Your forebrain gets frozen out of it and your hindbrain takes over. So basically, if you’re out in the Savannah and you turn and you see a lion running at you, you don’t want to sit and analyze that and decide, well, what’s the best approach here? It’s straight into fight or flight. When you have a patient who crashes in front of you, it’s the same thing. You immediately panic and go in the fight or flight. First, that’s not a good long-term prospect. So, say after the Air France crash, Airbus brought in a new procedure called the Golden Rules. So, it’s basically then, we look back, we look, aviator, navigate, communicate. It’s our version of airway We’re even in circulation.

Check, is the plane actually in a position that’s capable of flying? Are we pointing at a mountain? So, communicate with the people around you. Check if your autopilot’s working, check the automatics and stuff. So, we now default into that. That takes about 10 or 12 seconds, and that gets over the start of reflex, and we can then analyze things better and get our frontal cortex involved. Health care that day didn’t have that in place. So, they went into the fight or flight response and never really got back out of it. There’s two in this involved who were very competent, very experienced, and no doubt doing their best. But they ended up with tunnel vision of what was going on. They had a couple of theater nurses beside them offering them the tracheostomy kit, but they were so focused on what they were doing. They basically went in the tunnel vision and couldn’t hear what was going on around them. Unfortunately, Elaine ended up suffering brain damage and died in intensive care a few days later. Since that, Martin has then brought the whole aviation approach to the NHS in the UK. He produced a video, just a routine operation, which I think is now used in the induction of all new staff in the NHS across the board for the last decade.

And Martin has made phenomenal progress. I then set up a group called the Clinical Human Factors Group, which does a lot of training around the UK and trying to bring the human factors idea into health care. I say Martin’s probably done more for this aviation approach in health care than the rest of us combined. He’s made phenomenal progress. Hopefully, I’ll be standing on his shoulders and try and take it a bit further as well.

Thank you for sharing that. Thank you very much for joining me today.

Thanks, Eric. And see if people want any further information, my website, frameworksafety.com, has various articles written. And am I allowed to say that there’s some other podcasts on it as well? Other podcast articles?

Absolutely. Of course you may.

There’s information on that. If anyone wants to get in touch with me with any suggestions or ideas, I’m all ears as well.

Excellent. So frameworksafety.com?

That’s it. And I said there’s links to the book, there’s links to the TED Talk. There are various articles and so on I’ve written there. And I’m very interested if people have any feedback or any comments. Again, I’ve only got a certain amount of information. If people have other ideas or criticisms, I’m very happy to receive.

Thank you so much now. Incredible experience between experience as a surgeon and now as a captain on an A330.

Thank you, Eric. Thanks for having me. Hope you find it useful.

Definitely. Thank you.

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