Oops! Why Things Go Wrong (eBook)

Understanding & Controlling Error

Niall Downey (Autor)

eBook Download: EPUB

2024 | 1. Auflage
310 Seiten
Bookbaby (Verlag)
979-8-3509-5638-2 (ISBN)

Infos

Niall Downey, a cardio-thoracic surgeon who retrained as a commercial airline pilot uses his expertise in healthcare and aviation to explore the critical issue of managing human error. With examples from business, politics, sport, technology, finance, education and other fields, Downey makes a powerful case that by following some clear guidelines, any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast paced world, getting things wrong is impossible to avoid, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely beneficial in preventing avoidable catastrophes from occurring. An acknowledged expert in error management, Niall advises governments, healthcare organisations and major corporations on how to develop a systemic approach to controlling for human imperfection. Arguing that prevention is far preferable to denying responsibility after the fact, he gave an influential TEDx talk in 2016 outlining how healthcare could use aviation's experience to reduce tragic outcomes and improve patient safety. 'Niall Downey is perhaps the only person in the world who could write this important new book...an owner's manual on how to work, live and play safer by knowing how and why errors happen.' Dr Brian Goldman MD Mount Sinai Hospital, Toronto and author of 'The Secret Language of Doctors'.

Capt Niall Downey FRCSI attended St Columb's College, Derry, Northern Ireland and qualified as a doctor from Trinity College, Dublin, Ireland in 1993. He trained as a surgeon in Belfast and received his FRCSI in 1997. He was a trainee in cardio-thoracic surgery working as an SHO in the Royal Victoria Hospital, Belfast before returning to Dublin where he worked as a registrar in the National Cardiac Surgery Unit in the Mater Hospital and Our Lady's Children's Hospital, Crumlin. He subsequently retrained as an airline pilot with Aer Lingus in 1999 and combined aviation with medicine by working as an Accident & Emergency doctor for six years before focusing fully on aviation. After operating as a co-pilot on both the European and Trans-Atlantic fleets, he qualified as a captain in 2010. He is currently operating out of their Manchester base on the Airbus A330 Trans-Atlantic fleet. In 2011, Niall formed Frameworkhealth Ltd, a company providing aviation-style safety training modified specifically for healthcare which draws on his thirty-five years of experience between both industries. This project aims to share aviation's Safety Management System with healthcare in order to address the huge issue of Adverse Events, usually caused by systemic faults but often blamed on the last individual to have touched the ball. Niall aims to encourage healthcare to adopt a Just Culture, embed a systemic Human Factors approach and empower patients and their families to speak up as part of the crew. Niall has provided training courses for the new practice-based pharmacists in Northern Ireland in conjunction with NICPLD and has spoken at conferences in Northern Ireland, Republic of Ireland, Alderhey Trust in Liverpool, the Royal College of Physicians & Surgeons of Glasgow, the GMC, the PDA, the BMI London Independent Hospital, the Homerton Hospital in London and many others. Internationally, he has spoken at the World Football Academy Expert Meeting in Lisbon on Error Management's application in soccer and at the European Solid Organ Transplantation conference in Copenhagen in September 2019. In 2022, he spoke at the RSNA global radiology conference in Chicago and has been invited back in 2024. In 2016, Niall was a speaker at TEDx Stormont in Belfast. He was also appointed as an Expert Advisor that year to advise the Northern Ireland Executive's new Improvement Institute which was set up under the Bengoa Report on how aviation can help healthcare address the huge issue of human error and learn to manage it. In 2023, Niall had his first book, 'Oops! Why Things Go Wrong' published which explored the increasingly topical issue of error across industry and society generally and most importantly, how to address it. The book is already in its second print run after a higher than anticipated demand. The success of the book has led to many invitations from outside healthcare and Frameworkhealth has now evolved into Framework Safety Group Ltd in recognition of this broadening scope. Niall lives with his family in Newry, Northern Ireland. More information is available from www.frameworksafety.com and Niall is represented by Debbie at www.performanceinsights.co.uk for corporate speaking enquiries.

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Niall Downey, a cardio-thoracic surgeon who retrained as a commercial airline pilot uses his expertise in healthcare and aviation to explore the critical issue of managing human error. With examples from business, politics, sport, technology, finance, education and other fields, Downey makes a powerful case that by following some clear guidelines, any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast paced world, getting things wrong is impossible to avoid, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely beneficial in preventing avoidable catastrophes from occurring. An acknowledged expert in error management, Niall advises governments, healthcare organisations and major corporations on how to develop a systemic approach to controlling for human imperfection. Arguing that prevention is far preferable to denying responsibility after the fact, he gave an influential TEDx talk in 2016 outlining how healthcare could use aviation's experience to reduce tragic outcomes and improve patient safety. 'Niall Downey is perhaps the only person in the world who could write this important new book...an owner's manual on how to work, live and play safer by knowing how and why errors happen.'Dr Brian Goldman MDMount Sinai Hospital, Toronto and author of 'The Secret Language of Doctors'. We so often sleepwalk through life, assuming the systems around us work for the best. Being attentive to human error not only wakes us from that stupor, but makes us realise the ways in which we can be attentive to our own mistakes. As relevant to big business, industry and elite sport as it is to the individual, error management and how to be alert to it, is such an important conversation to be had in all walks of life. Niall's vast experience and curiosity for the world, make him the perfect person to write this book. Ms Orla ChennaouiWriter, journalist, columnist, TV presenter and Lead Presenter for Eurosport's cycling coverage. Niall takes the reader on a fascinating journey through a condition we all suffer from, human error. From sport and surgery to aviation and agriculture, this book details both the unfortunate and the catastrophic, why error happens and, most importantly, what we can do about it' Mark Gallagher, Formula 1 Executive, writer, broadcaster. Author of 'The Business of Winning Strategic Success from Formula One' In this book, Niall Downey takes a look at error through multiple lenses: from aviation to sport, justice to politics. As a surgeon-turned-pilot, Downey has skin in the game and he casts his net wide to find answers for why things go wrong. Dr Steven Shorrock C.ErgHFChartered Psychologist and Chartered Human Factors Specialist, Senior HF and Safety Specialist at Eurocontrol, Editor in Chief of Hindsight magazine. Adjunct Associate Professor University of the Sunshine Coast, Honorary Clinical Tutor University of EdinburghHuman connections are essential to delivering person-centred care and sometimes the care environment, culture or the way we do things creates harm. In healthcare this can be catastrophic - this book provides safety critical insights and methods to help eliminate avoidable harm. A must read for healthcare teams. Professor Charlotte McArdle DrSc MScDeputy Chief Nursing Officer NHS England. Former Chief Nursing Officer, Northern Ireland. "e;Oops! Why Things Go Wrong"e; is essential reading for every person who wants to improve their leadership and teamwork skills, be resilient and survive crises. Downey's remarkable and unique knowledge taken from years of experience commanding commercial airline cockpits and surgeries, puts you into the Captain's seat to maximise safety, quality and save lives."e;Captain Richard de Crespigny AM, Pilot-in-Command and author of QF32Retired Airbus A380 Captain, Qantas.

Textauszug

Chapter 1

Come Fly With Me!

I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven flight control computers fails in my Airbus A320 aircraft. The plane politely ‘bings’ and flashes an unthreatening amber light to alert me to this fact. I co-ordinate with my co-pilot to ensure the safety of the flight is assured, and that the plane is performing as expected under the circumstances. We check if there are any relevant checklists to perform. There aren’t. Reassured, I push a button to acknowledge via our computer interface on the ECAM control panel that I’m aware of the failure and then again to acknowledge that I am aware of the status of our aircraft systems.

And that’s pretty much it! This could have been a big problem, but thankfully, the flight control computer’s error, whatever it was, has minimal impact.

Our $100 million airplane is designed around the concept of redundancy. We expect that things will go wrong, so we have back-ups for more or less everything. If a computer or a system fails, its back-up takes over with little or no fuss. Our A320 is a Fly-By-Wire (FBW) aeroplane, which means that our controls (side-stick, rudder pedals, thrust levers and so on) are not physically connected to the flight controls, but via multiple levels of computing power which allows some pretty nifty programming to smooth out my inputs making me look better than I actually am. It also provides protections to stop me exceeding the limits of the aeroplane, for instance banking or pitching beyond pre-determined limits, flying too fast or too slow and so on. It also saves weight by removing quite a few cables, pulleys and levers which were previously needed to link us to the control surfaces. This means we save on fuel, and thereby our plane is more economical.

There are seven flight control computers, namely, two Elevator and Aileron Computers (ELAC 1 & 2), three Spoiler and Elevator Computers (SEC 1, 2 & 3) and two Flight Augmentation Computers (FAC 1 & 2). In a reassuringly paranoid mindset, each computer in a set is supplied by a different vendor, uses software provided by a different vendor and each processor is even programmed in a different computer language, all to minimise the chance of everything failing at once.

These sophisticated bits of kit mean that the aeroplane operates in what Airbus calls Normal Law most of the time. This is designed to approximate what a conventional aeroplane feels like to fly, although fewer and fewer of us are getting the opportunity to fly one of those, as many pilots start their careers in a modern FBW aircraft and never revert to anything else. We take off in Ground Mode which gently transitions into Flight Mode a few seconds after getting airborne. On final approach to landing, it moves into Flare Mode as we approach touchdown, again to make it feel more like a conventional aeroplane, and so it behaves as our brains expect machinery to behave. As noted, it protects me from over-speeding, under-speeding, stalling, excessive g-loads, pitch and bank angles. It adjusts how it interprets my input according to our speed, altitude and so on. Overall, it’s an incredible bit of kit, although it’s not fool-proof.

The failure of our ELAC 1 has minimal impact on our day except that we have lost a layer of redundancy. This becomes of more interest to us when we hear a second bing shortly afterwards to let us know that our second computer, ELAC 2, has come out in sympathy with its friend. We go through the same procedure again and assess that we are still in good shape except that the plane has now degraded into what is called Alternate Law. This is similar to Normal Law but with fewer protections. We retain our g-load protection but lose our bank angle and pitch protections. Our low and high-speed protections are not as comprehensive but we have some support. This is a slightly bigger deal; it means we have to become more alert, but the aeroplane still flies normally.

Unfortunately, our day then gets progressively worse. The plane informs us with increasing levels of urgency (continuous high pitched chimes and red flashing lights) that further flight control computers have dropped out, leaving us in Direct Law, which essentially turns the plane into a normal, conventional aeroplane with all our protections lost and no autopilot to help me fly.

As a final insult, we lose all electrical power which drops us into the lowest available flight mode, Mechanical Back-up. This leaves us with only two, fairly crude connections to our flight controls, namely our trim wheel in the centre pedestal which moves the elevator on the tail-plane allowing us some control to point the plane up or down, and the rudder pedals, again connecting us to the tail of the aeroplane and the rudder giving us some left/right turn control. This is designed to enable us to fly roughly straight and level to buy enough time to get at least one computer re-booted and give us enough control to land the plane safely. Our engines are still working but without our Autothrust mode (our cruise control, if you like). These three inputs are all we have left.

It’s a bad day at the office, but it could have been a lot worse. Aviation’s attitude to error has provided us with many layers of protection to allow us to navigate our way safely back from multiple failures. In this book I will explore these and show how, with minimal modification, they can be used to achieve a similar goal in both our professional and personal lives, regardless of what field we work in or our circumstances.

***

I’ve always been fascinated by mistakes. In the late 1970s my brother gave me a book, The Book of Heroic Failures by Stephen Pile, the President of the Not Terribly Good Club of Great Britain. It opened my eyes to such glorious errors as the prisoners in Saltillo Prison in Mexico who spent five months digging a tunnel in an audacious escape plan only to find upon surfacing that it led into the nearby courtroom where many of them had been sentenced – all seventy-five were swiftly returned to prison. Or the equally impressive error Mrs Beatrice Park made by mistaking the accelerator for the clutch during her fifth attempt at her driving test in 1969, which resulted in her and her examiner sitting on the roof of the car in the middle of the River Wey in Guildford waiting to be rescued. The examiner had to be sent home and when Mrs Park enquired whether she had passed she was told, ‘We cannot say until we have seen the examiner’s report.’ It also exposed truly brilliant errors like Decca Records (as well as Pye, Columbia and HMV, in fairness to Decca) who turned down The Beatles with the now legendary quote, ‘We don’t like their sound, groups of guitars are on the way out’. This great tradition has been carried on by the twelve publishing houses who turned down J.K. Rowling’s book about a young wizard named Harry Potter in the 1990s. Error is not simply a historical curiosity. It’s alive and well.

My interest in error dwindled as I progressed through my education as the emphasis was on the need to avoid it. This reached its zenith as I trained as a cardio-thoracic surgeon in Belfast and Dublin, where the idea of error was simply anathema. The underlying message seemed to be: ‘Don’t make a mistake. If you do make a mistake, don’t admit to it and don’t make the same mistake again.’ I think this attitude is fairly ubiquitous around the world.

But my view on error was challenged when I left healthcare to retrain as an airline pilot in 1999. In aviation, there is the idea that error is inevitable, and therefore something integral to our whole Safety Management System. When I went through our Command Training and Check process in 2010, an arduous series of simulation training and real flights taking around two months, I gradually realised that the position of the captain, the person in command of the flight, was not all about technical aircraft knowledge (although obviously a certain level is essential) but more about the anticipation and management of error. My interest in error, and the broader Human Factors and ergonomics field encompassing it, was reborn. I realised belatedly that many of the ideas I’d suggested whilst a surgical trainee were in fact the same ones which aviation had embraced as the bedrock of their entire safety philosophy, and that healthcare could benefit hugely from the implementation of a similar approach.

During the following year, 2011, I established Frameworkhealth Ltd, which focused on the transfer of the aviation approach to error management into healthcare with the aim of reducing avoidable harm from adverse events. What follows is an exploration of what I have learnt over the last decade from experts on the subject of error, and how we can use this learning in many areas including healthcare, transport and maybe even how we engage with our social and political leaders.

This book will explore how we have become quite exposed by twenty-first century advances. We have progressed much faster than evolution can cater for, resulting in a brain structure and function which increases the likelihood of error. In the past this was of little consequence, and may even have been a good trade-off in...

Produkt-Details

• Erscheint lt. Verlag: 24.4.2024
• Sprache: englisch
• Themenwelt: Wirtschaft ► Betriebswirtschaft / Management ► Unternehmensführung / Management
• ISBN-13: 979-8-3509-5638-2 / 9798350956382