How to Get Things Right?
How to Get Things Right?
Recently a post “Death by Computer” was viral on social media.
The crew and passengers of Ethiopian Airline Flight # ET302 on board a brand new Boeing 737 MAX 8 never had a chance. Totally 157 people perished. The less than three months old plane had a new software on it. Boeing built the 737 MAX version, in layman’s term, they built the aircraft with a larger and more efficient engine. However, this larger engine, which delivered a further 14% fuel efficiency had to be fitted further forward under the low wings of the 737. This potentially may cause the plane to stall. Stalling is bad. It is basically when a plane stops flying and starts falling. To avoid this, Boeing installed the new MCAS (Maneuvering Characteristics Augmentations System) software. This software is designed to tell the plane to move its nose down to increase its speed and avoid it from stalling.
So here comes the problem. On the plane, there is a sensor called the Alpha Vane which measures the Angle of Attack (AOA) of the plane. It looks like a small little wing, and they have two of it, one on the pilot side, and the other on the co-pilot’s. The sensor’s job is to tell the computer the angle the plane is flying at. And if the AOA of the plane is too high, this will result in the plane stalling. Typically the AOA is below 15 to 20 degrees, and the new MCAS software will push the plane’s nose down if it thinks that the AOA is too high.
Now, with this flight, the Alpha Vane sensor measuring the AOA on the Captain’s side was reported to be faulty. So they changed it. That fault was reported from the equally harrowing flight from Bali to Jakarta. On the fateful final flight, the plane which arrived from Bali the night before, had the sensor changed, and then it took off in the morning. No one knew what was really wrong with the plane, or about the new MCAS software. No one. Not the maintenance folks, and in fact not even the pilot. He apparently wasn’t trained on it yet.
So they flew the plane. And once in the air, the faulty sensor told the computer that the plane is stalling. The computer then, without the pilot ever knowing pushed the nose of the aircraft down further, while the pilot was trying to raise the plane. In this battle between the pilot and the computer, the computer won. And the pilot, the crew, and the passengers lost and they died. The plane was too low, and the pilot didn’t have enough air to raise the aircraft and fly it.
The computer literally flew the plane into the ocean. A few weeks later, Boeing issued an update on the aircraft, and informed that should the plane have an issue with it’s AOA sensors, one of the way to stop the computer was to switch it off! Apparently, 189 lives could have been saved, had the pilot knew about the software and flipped a switch to turn it off. A switch! A single simple switch was the difference between life and death.
More than 300 Boeing 737 Max planes are in operation, and more than 5,000 have been ordered worldwide since 2017. I have traveled several times on Boeing 737 MAX 8 of Fly Dubai, SpiceJet and Jet Airways. After reading the above post, I broke a coconut and prayed his Almighty for saving my life on those flights. This incident reminded me of the book I had read almost a decade back. That is Checklist Manifesto – How to get things right, by Atul Gawande. Let me quote that incident from the book. In 1935, at the Wright Field in Ohio, the Army Air Force held a tryout among aircraft companies for its new bomber. Boeing entered its B-17. The plane was a complicated one, and even though the pilot was highly trained and experienced after the plane took off, it stalled, crashed and burst into flames. This was all due to a simple routine step that had been forgotten. Due to this tragedy, pilots began to adopt the use of checklists and the Checklist Manifesto.
However, we doctors often work in teams and do not use a computer to make decisions. Specifically, we surgeons make many many quick and on-the-spot decisions to safeguard patients. Are we immune to mistakes or forgetting routine steps? Definitely not. To quote Atul Gawande, “We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at. What is needed, however, isn’t just that people working together be nice to each other. It is discipline…”
Incidentally, I was introduced to this book nearly a decade back by my senior friend Dr. Ravi Nayyar while traveling together on a plane, from Mangalore and Bangalore. Ever since I read that book, I adopted and religiously following the WHO recommended Surgical safety checklist. Atul Gawande was instrumental in designing the Surgical safety checklist. This checklist has saved us as well as our patients from potential complications at least four times. Let me quote an incident. We had to drain the neck abscess of a Haemophiliac patient. His Haemophilia correction was done adequately, and blood transfusion was arranged as one of the pre-anesthesia condition on the checklist is “Risk of >500ml blood loss (7ml/kg in children)?” However, before the induction of anesthesia, I demanded an additional intravenous line. Anaesthesiologist replied saying, she tried several times and could manage only one as the patient had multiple blood transfusions earlier and most veins are thrombotic and blocked. She couldn’t insert a central venous catheter through the neck as there was neck abscess. However, I insisted. After trying for almost an hour, she could get another line. As fate would have it, during the positioning of the patient, one of the junior nursing staff, pulled out one of the IV lines. And that patient had high intra-operative bleeding requiring multiple blood transfusions. Since we had an additional line ready, we could easily control the situation.
As Gawande aptly puts it, “Humans aren’t good at discipline. Checklists provide the ability the be more disciplined and more creative. This sounds like a weird combination, but it’s true. And it is essential to improve discipline because without it things can go very, very wrong. It isn’t natural, so we have to make an effort if we want to improve. If a pilot forgets to flip a switch, lives are at stake. The same goes for a doctor who forgets to wash his hands. In business, money, and reputation is at stake.”
Atul Gawande, a surgeon, a public health researcher, a celebrated author, and columnist for the New York Times. He has used several case studies to make the argument for checklist use in a myriad of other fields. In this non-fiction book, Atul has discussed how the medical professions and the business world could significantly benefit from the implementation of checklists. I have personally experienced the improved safety, consistency, and efficiency that could be created by implementing a surgical safety checklist. Gawande’s book provides some other compelling arguments for the use of checklists in business. He has used a section of his book to offer some critical guidelines for developing a list that will be useful. It’s a must for all medical professionals and other professionals where human safety is involved.
Dr. Prahlada N.B, Chitradurga