It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic. Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview: “…we got many donated ventilators. Many … Continue reading It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic.

Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview:

“…we got many donated ventilators. Many hospitals got that, and we needed them. … But it’s like having 10 different remote controls for 10 different TVs. It takes some time to figure that out. And we definitely saw things go wrong as people struggled to figure out how this remote control works from that one.”

“We had many patients being transferred from overloaded hospitals. And when patients come in a batch of 10 or 20, 30, 40, it is really a setup for things going wrong. So you have to be extremely careful in keeping the patients distinguished. We have to have a system set up to accept the transfers … [and] take the time to carefully sort patients out, especially if every patient comes with the same diagnosis, it is easy to mix patients up.”

And my favorite, even though it isn’t necessarily COVID-19 related:

“For example, … [with] a patient with diabetes … it won’t let me just put “diabetes.” It has to pick out one of the 50 possible variations of on- or off- insulin — with kidney problems, with neurologic problems and to what degree, in what stage — which are important, but I know that it’s there for billing. And each time I’m about to write about it, these 25 different things pop up and I have to address them right now. But of course, I’m not thinking about the billing diagnosis. I want to think about the diabetes. But this gets in the way of my train of thought. And it distracts me. And so I lose what I’m doing if I have to attend to these many things. And that’s really kind of the theme of medical records in the electronic form is that they’re made to be simple for billing and they’re not as logical, or they don’t think in the same logical way that clinicians do.”

Lion Air Crash from October 2018

From CNN: The passengers on the Lion Air 610 flight were on board one of Boeing’s newest, most advanced planes. The pilot and co-pilot of the 737 MAX 8 were more than experienced, with around 11,000 flying hours between them. The weather conditions were not an issue and the flight was routine. So what caused … Continue reading Lion Air Crash from October 2018

From CNN:

The passengers on the Lion Air 610 flight were on board one of Boeing’s newest, most advanced planes. The pilot and co-pilot of the 737 MAX 8 were more than experienced, with around 11,000 flying hours between them. The weather conditions were not an issue and the flight was routine. So what caused that plane to crash into the Java Sea just 13 minutes after takeoff?

I’ve been waiting for updated information on the Lion Air crash before posting details. When I first read about the accident it struck me as a collection of human factors safety violations in design. I’ve pulled together some of the news reports on the crash, organized by the types of problems experienced on the airplane.

1. “a cacophony of warnings”
Fortune Magazine reported on the number of warnings and alarms that began to sound as soon as the plane took flight. These same alarms occurred on its previous flight and there is some blaming of the victims here when they ask “If a previous crew was able to handle it, why not this one?”

The alerts included a so-called stick shaker — a loud device that makes a thumping noise and vibrates the control column to warn pilots they’re in danger of losing lift on the wings — and instruments that registered different readings for the captain and copilot, according to data presented to a panel of lawmakers in Jakarta Thursday.

2. New automation features, no training
The plane included new “anti-stall” technology that the airlines say was not explained well nor included in Boeing training materials.

In the past week, Boeing has stepped up its response by pushing back on suggestions that the company could have better alerted its customers to the jet’s new anti-stall feature. The three largest U.S. pilot unions and Lion Air’s operations director, Zwingly Silalahi, have expressed concern over what they said was a lack of information.

As was previously revealed by investigators, the plane’s angle-of-attack sensor on the captain’s side was providing dramatically different readings than the same device feeding the copilot’s instruments.

Angle of attack registers whether the plane’s nose is pointed above or below the oncoming air flow. A reading showing the nose is too high could signal a dangerous stall and the captain’s sensor was indicating more than 20 degrees higher than its counterpart. The stick shaker was activated on the captain’s side of the plane, but not the copilot’s, according to the data.

And more from CNN:

“Generally speaking, when there is a new delivery of aircraft — even though they are the same family — airline operators are required to send their pilots for training,” Bijan Vasigh, professor of economics and finance at Embry-Riddle Aeronautical University, told CNN.

Those training sessions generally take only a few days, but they give the pilots time to familiarize themselves with any new features or changes to the system, Vasigh said.
One of the MAX 8’s new features is an anti-stalling device, the maneuvering characteristics augmentation system (MCAS). If the MCAS detects that the plane is flying too slowly or steeply, and at risk of stalling, it can automatically lower the airplane’s nose.

It’s meant to be a safety mechanism. But the problem, according to Lion Air and a growing chorus of international pilots, was that no one knew about that system. Zwingli Silalahi, Lion Air’s operational director, said that Boeing did not suggest additional training for pilots operating the 737 MAX 8. “We didn’t receive any information from Boeing or from regulator about that additional training for our pilots,” Zwingli told CNN Wednesday.

“We don’t have that in the manual of the Boeing 737 MAX 8. That’s why we don’t have the special training for that specific situation,” he said.