Tuesday, March 29, 2016

The Retrospectoscope and "The Weather Channel Special Presentation: Why Planes Crash: Sudden impact"

I was cruising the TV Menu recently and came across "The Weather Channel Special Presentation: Why Planes Crash: Sudden impact", so i got hooked. It was a presentation on several famous airline crashes over the past 40 years, where bad weather played an integral part in the events. I rapidly had two thoughts: I may never fly again and I can emphasize with the pilots who, post-mortem, are blamed for the crash. In each event the FAA sends a crew in and inevitably claim "pilot error". "The pilot should have immediately turned around, the pilot should have changed courses, the pilot should not have touched down but taken another run at the runway."... and so on.
             I remembered a conversation with world renown FAA crash inspector Alan Diehl. He seems to agree that it is easy in the midst of an investigation to rapidly conclude that the pilot made a wrong choice and should have chosen an alternate action but made a mistake. I can remember many times in my career whereby the situation in the area rapidly goes sour, adrenaline flows, and either I or another MD makes a decision based on little information and goes with it, and things go right. You are now a hero. It goes wrong and you are crucified. Same with the pilots who make decisions based on what information is in front of them and things go right and they are heroes. People shake their heads and then their hands and say that they are proud of that person, but no one does that when things go wrong. So the lesson passed on by the FAA for these events were "we now teach pilots about updrafts. We teach pilots about short wet runways and the dangers of going full speed for a landing........." etc.
           I am told that behind all this, there is team training that allows those in charge, the decision makers, to work with the team to get all the information they need to consider their options and work to come up with a choice of action with a proposed best outcome. Sometimes that lifesaving decision can be to ignore the tower who is telling you to keep flying the plane and not land on a river, and that type of rapid decision processing based on input from those who trust you in the room is what they need. So do we teach folks how to stop for a minute or two, discuss with those around us what we think is the best course of action to take based on the limited information we have or do we just teach them how to deal with that particular scenario- but not a global management process?
                 While it may be possible to teach a pilot how to deal with every possible weather danger they may face, I just do not think you can teach a Surgeon, fire-fighter or police officer how to deal w/ the multitude of dangers out there. We seem to teach folks to make a decision and there may be a 50:50 chance of surviving and if you live you are a hero. There has to be a better way to do this. There has to be a way to teach individuals and teams how to control panic, assesses the situation, come up with valid options in a few minutes and go with the plan. ALSO, we need a BLACK BOX. We need to know what people are thinking and why the make these choices in the midst of danger so we can understand their decision to forge ahead in spite of the danger we say is "obviously in front of them". I hope to touch base with Pirooz Eghtesady at Wash.U to discuss his paper on this subject.

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