medical safety: lessons from space by kevin fong
TRANSCRIPT
Life, Death and MistakesKevin Fong
Consultant AnaesthetistUniversity College London Hospital
Honorary Chair in Public Engagement for Science and Medicine
University College London
Kent, Surrey, Sussex Air Ambulance
Why Don’t Doctors Behave More Like Pilots?
Why Don’t Doctors Behave More Like Pilots?
Air Safety: Comparison with other modes of transport
Deaths per billion passenger kilometres
Air 0.05 Bus 0.4 Rail 0.6 Van 1.2
Water 2.6 Car 3.1
Bicycle 44.6 Foot 54.2
Motorcycle 108.9
DATA: Survivability of Accidents Involving. Part 121 U.S. Air Carrier Operations,1983 Through 2000 NTSB/SR-01/01 March 2001 PB2001-917001 Notation 7322
Air Safety: Comparison with other modes of transport
Deaths per billion passenger hours
Bus 11.1 Rail 30 Air 30.8
Water 50 Van 60 Car 130
Foot 220 Bicycle 550
Motorcycle 4840
Air Safety: Comparison with other modes of transport
Deaths per billion passenger journeys
Bus 4.3 Rail 20 Van 20 Car 40
Foot 40 Water 90 Air 117
Bicycle 170 Motorcycle 1640
• DATA: Survivability of Accidents Involving. Part 121 U.S. Air Carrier Operations,1983 Through 2000 NTSB/SR-01/01 March 2001 PB2001-917001 Notation 7322
Why Don’t Doctors Behave More Like Bus Drivers?
The Right Lessons from The Right Stuff.
US Airways Flight 1549, Jan 15 2009
Crew Resource Management
Eisen LA, Savel RH. Chest. 2009 Sep;136(3):910-7. What went right: lessons for the intensivist from the crew of US Airways Flight 1549.
Data!!!
Flight Data and Cockpit Voice Recorders
Engineering
Engineering the Problem Out of the System
Engineering the Problem Out of the System ?
Engineering the Problem Out of the System
Engineering the Problem Out of the System
Human Factors&
Crew Resource Management
Crew Resource Management
Crew Resource Management
Cooper, G. E., White, M. D., & Lauber, J. K. (1980). Resource Management on the Flightdeck: Proceedings of an Industry Workshop. Moffett Field.
Crew Resource Management
Cooper, G. E., White, M. D., & Lauber, J. K. (1980). Resource Management on the Flightdeck: Proceedings of a NASA/ Industry Workshop. NASA Moffett Field.
The Challenger Accident
STS 51-L – Challenger Mission Jan 1986
STS 107 – ColumbiaMission Feb 2003
Investigation of the Launch Decision
Report of the Presidential Commission on the Space Shuttle Challenger Accident
The Roger’s Commission
Challenger: Background
• Jan 1986: NASA behind on launch schedule• NASA are using launch frequency as a key
performance indicator• Many launch delays for Challenger• Pressure ++ to launch on Jan 28 1986• Repeated concerns expressed over O-Rings
Roger Boisjoly’s Handwritten Note:
53 Degrees Farenheit = 12 Degrees Celcius (approx)
Roger Boisjoly’s Handwritten Note:
Crew Resource Management
Cooper, G. E., White, M. D., & Lauber, J. K. (1980). Resource Management on the Flightdeck: Proceedings of a NASA/ Industry Workshop. NASA Moffett Field.
Challenger STS 51-L - 1986
Columbia STS 107 - 2003
Richard Feynmann’s Appendix to the Roger’s Commission Report
“For a successful technology, reality must take precedence
over public relations, for nature cannot be fooled.”
Kent, Surrey, Sussex Air Ambulance
Life, Death and MistakesKevin Fong
Consultant AnaesthetistUniversity College London Hospital
Honorary Chair in Public Engagement for Science and Medicine
University College London