Training for Safety: What the Airlines really did … and do.

Halldale Publisher and CEO Andy Smith, places into context his insights gained from several decades of watching the civil aviation sector achieve unprecedented levels of safety. The Herculean advancements in civil aviation safety may be tailored to and replicated by the healthcare industry.

Career- long learning is well established within the airlines' safety culture. Image Credit: CAE

At each and every healthcare training, safety or education event reference is made to “what the airlines did” to achieve their unprecedented record of safety. This is quickly passed over with one or two comments that indicate a varying level of knowledge of how airline personnel are trained and a statement to the effect that “of course medicine, or the human body, is considerably more complex than airplanes. So moving on…..”

While that is of course true, there are multiple lessons that the healthcare sector can learn from aviation, another complex system of many moving parts, people and opportunities for miscommunication and error. The airline industry has created many procedures and actions that can be translated and transferred to help support an improve healthcare.

Improved training is only one element of the mix. Improvements to technologies such as avionics, improved engine and airframe reliability, instruments to warn of “controlled flight into terrain” i.e., an impending crash, and improved air traffic control all had a major impact on airline safety, as changes in medical technologies will have in healthcare safety.

The airline sector, like healthcare, is a people business. Without well trained people working together as a team, all the technology in the world will make little difference. So, just as the healthcare sector improves its “avionics” via electronic health records, and its hospitals and OR’s with increasing technology, so too, it must improve the education and training of all its personnel.

As acknowledged by increasing numbers of health experts, the healthcare community must transform its system into a patient centered, safety driven standard of operation, just as the airlines had to do, to enable its transition from a high risk to a very low risk business. (CAT issue 4 2012, People, Planes, and Pilots, by Chris Lehman, fig 2 p 7)

Without that cultural shift it is difficult to see how the transformational change needed in healthcare and healthcare training will be generated. In a recent online forum the audience was told, “we have been talking healthcare safety for 30 years.” Biting off the obvious retort of “OK, where is the improvement then?” I was left to reflect that the airlines have been “doing airline safety” for about the same time. Surely it is time for more action and less talk; there is huge room for improvement even if, as was the case in aviation, the tools available are not yet fully up to requirement. That they soon will be is beyond doubt; and we all need to start the difficult process of changing ourselves.

The current excellent airline record of safety stems from actions taken across the history of flight but the vast improvement took place in the last 30 years. Around 1980 the major airlines realized that with no improvement in accident rates, [extrapolating the size of the global fleet to meet the expected needs of the year 2000, roughly a doubling of capacity], would lead to an accident a week globally by the early 2000s.

The fact that this did not happen was due to the actions of national governments, the entire aviation community: airlines, aircraft manufacturers, the avionics industry, the simulation and training industry, safety and professional organizations and others. Only latterly did national and global air regulators codify these changes into new standard operating procedures, though they watched closely and encouraged the industry to rectify its problems. It should be noted that these actions were taken for the safety of crews and passengers but also to ensure the commercial survivability of a critical industry. Pilots, cabin crew, airline and airport managers, air traffic controllers and maintainers all needed to get it right. After all, passengers can choose not to fly, and they can certainly carefully select the airline on which they fly. So here are some of the highlights of the airline industry pertaining to training for safety:

1. The airline industry is a safety based industry in which a culture of continuous career-long learning, improvement and evaluation is embedded.
2. Such is the cost of flight training that recruits in many countries are subject to academic and psychomotor skills testing before they are accepted into a program to ensure that the likelihood of completing the course is high -- 97% or higher is typical. This is both to ensure that limited training resources are not wasted but also that funding for the program can be secured.
3. It is also an industry in which proficiency is thoroughly tested prior to qualification. Mandated refresher training and proficiency simulator check rides for pilots are carried out every six months until retirement. Failure in the check ride would require remediation and a further check ride prior to a return to line operations.
4. Before transitioning to a new aircraft type or model the pilots undergo “bridge training” to qualify them for the type of aircraft they will be flying, the “type rating” that proves proficiency on that aircraft type.
5. Cabin crews are also required to undergo similar type rating training. The number of cross qualifications is limited to ensure that the opportunity for confusion is minimal. If you are required to work with your fellow cabin crew to evacuate 150 or more passengers from a downed aircraft in less than 90 seconds this really helps!
6. Regarding the introduction of new equipment, no civilian airliner is ever flown until the entire flight deck crew has demonstrated its ability to proficiently operate the aircraft in the simulator. This enables the pilots to fly the actual aircraft for the first time with a full load of paying passengers in the cabin.
7. Also in that cabin is a crew that has been fully trained to operate effectively in normal flight and if necessary evacuate all passengers safely in an emergency. They are also trained and encouraged to alert the pilots to anything which, in their opinion, may endanger operations. The best captains are the first to praise them to the passengers. (CEET pic)David will you please insert picture Andy requires
8. The airlines have spent considerable sums developing CRM (crew resource management) training for its flight crew and maintenance teams working on crisis management and communications, not only for aircrew but also for maintainers, to ensure “hand offs” to the operators are thorough.
9. The airline industry has deployed pre- flight briefings, ‘walk arounds’ and pre-flight checks for years. These latter are not options for the teams involved and failures and avoidance are heavily penalized.
10. In more recent years as personnel have become more mobile the industry has also realized the need to standardize where possible the language used during flight to ensure that when the pressure is on there is less chance for misunderstanding. ‘Aviation English’ is now taught in an increasing number of locations around the world.

The airlines today have an enviable safety record. This benchmark is one that they are well aware is constantly under threat from changes in technology, an expected doubling of passenger capacity again in the next two decades, the loss of many experienced pilots, the lack of prior military flight hours for new pilot accessions, the way incoming recruits learn and so on. As a global industry (from the news reporting viewpoint) the industry is also aware that the biggest growth today is in areas of the world with the smallest cadre of experienced pilots and the lowest training capacity. It is acutely aware that standards will be under pressure and must be maintained and improved. Globally it is estimated that the annual need for pilots is about 25,000 per year while training capacity might provide about 15,000 of whom about 11,000 may be trained to currently acceptable levels. The numbers for cabin crew, maintainers and air traffic controllers needed is similarly stark.

Cabin Crew members have been trained to operate in normal flight and emergency situations. Image Credit: Czech Airlines

Maintaining the Standard

Technology is constantly changing and has benefited many industries including the airlines. Increasing automation has lessened the pilot workload leading to a two person cockpit in all commercial jets. It has also blunted the manual flying skills of many pilots who have come to rely on automation and in some cases have not recognized warning signs that a previous generation had. As a result the aircraft and avionics manufacturers with the airlines and the simulation manufacturers have come together to redress the balance and build training devices and curricula to correct this training gap.

Recruitment is a problem and this generation of recruits would prefer accounting and law to piloting an aircraft (or becoming a surgeon?). Many governments have reduced training funding and in some cases have put in place legislation that will slow the supply of pilots in the pipeline. In addition the U.S. government imposed restrictions on flight hours. That alone increased the need for 5% more pilots in 2014.

The industry has responded by proposing what is seen by many as a radical new training program. Known as MPL, the Multi Crew Pilot License, this program is designed to produce a proficient pilot able to sit in the right hand seat of a commercial aircraft as co-pilot through the very heavy use of simulation and a curriculum specifically designed to produce an airline pilot. The traditional route of flying progressively bigger, more complex aircraft and accumulating hours of general flying has been replaced in MPL with a tailored, carefully designed course which must be sponsored/proctored by an airline. Uptake is far from universal as the cost of the simulation and the need for airlines to sponsor the programs means that few entities can easily afford it and as ever there is resistance from established programs. But it seems likely that simulation- intensive primary training schemes will eventually be adopted by most.

The parallels between the airlines and the healthcare sector are again close. In another instance there does not appear to be a shortage of personnel aspiring for a healthcare career. In the US alone 46,000 potential nurses were turned away in 2006 and last year about 1,500 medical students were also turned away due to a lack of residency programs, indicating an accession pipeline as well as a funding problem.

The retirement issue for the airline and healthcare industry is also similar and we are at the beginning of the “baby boomer retirement spike”. In both cases, as the professions become less attractive, it seems likely that the retirement rate may be steeper than expected. An aging population and growth in services, and in the US, the emerging challenges of the Affordable Care Act of March 2010, seem to indicate a large and growing gap between the service expected and the sector’s ability to supply it.

It seems doubtful at this time that either the airline sector or the healthcare sector can cover the need for its services. Just as the airlines have moved to streamline their selection, training and supply system it seems the healthcare profession needs to do the same. A radically new way in which healthcare students are trained, coupled with a significant reduction in the time it takes to produce a trained doctor, nurse or other healthcare professional, all done while the hours available for this training have been drastically cut seems to be required.

It will certainly take an acceptance that the current model is broken or at least outmoded and will no longer serve. Once that consensus is reached the sector will have to work together with its suppliers of instruments and simulators to devise a way ahead. The “wheel” cannot be continually reinvented and we do not have the luxury of time. As much standardization of procedures and training as possible will need to be sought. How are hospitals to learn to fly?

First of all a “no fault found reporting” system has been key to improving airline safety. Near misses, errors and problems with procedures or equipment are required to be reported and not just within an airline but, if needed, globally. They are tolerated because if they were not the errors would be hidden and no “teaching moment” would result. Outright transgressions are not tolerated. (MEdSim has already-reported that some practitioners are reluctant to report improvements to procedures or protocol initiatives for fear that previous errors are highlighted and would negatively affect their practice, hospital, or other entity. It may be impossible to completely change this state of affairs but it surely must be possible to share best practice?)

The airlines have become heavily regulated with mandatory training specified by government. While this is seen as a contributor to the overall success of the industry, and it is, it also slows down the adoption of new technology which is costly at a time of such rapid change, as each device must be approved for its training task. A surer way forward in the healthcare sector, especially given its complexity, would seem to be to incorporate a “systems approach” where medical boards, specialty associations, medical organizations and medical schools adapt a uniform process and, as in aviation, for equipment manufacturers, training technology companies, educational specialist to be involved in the process with boards, educators and practitioners.

Finally to return to the original theme of a needed change in culture toward safety for staff and patients, two other airline aphorisms come to mind:

1. There are old pilots and there are bold pilots but there are no old bold pilots.
2. If you think training is expensive try paying for an accident.

About the author:

Andrew Smith, the publisher and CEO of Halldale Media Group, has been observing for more than two decades the returns on investment, efficiencies and other benefits of using technology-enabled learning in the military,civil aviation community and other high risk sectors. His newfound professional passion is to help educate and inform the healthcare sector about the opportunity to improve patient safety and achieve other ROIs from their investments in learning technologies.