I was once given the wrong prescription medication for my daughter, who has multiple health issues, by a pharmacist. The medicine was one that I recognized as a heart medication--my daughter has no problems with her heart. It was a serious error, but when I returned to the pharmacy to show them the mistake, the pharmacist began explaining to me, without looking at the bottle of pills, that there were safeguards in place making it impossible for her to make a mistake.
I immediately thought about everything I had learned, and taught my students over the years, about human error management. I recalled how one of the fundamental principles of the crew resource management (CRM) program I helped develop at my airline was that humans are imperfect and will always make unintentional mistakes. The flight instructor in me felt compelled to teach this pharmacist about how her flawed thinking made it more likely that she would continue to make mistakes that went unnoticed.
The pharmacist had other ideas. She persisted, explaining how her pharmacy’s system of barcodes and other mechanisms for dispensing medications made it impossible for her to make the kind of mistake that I was holding in my hand. Putting to use some of the tools I had learned for enhancing communication, I tried to ease her defensiveness by explaining that I wasn’t upset that an error had been made, but that it was unsafe for her to believe that mistakes couldn’t happen--that she would not be looking out for errors if she put too much trust in her system. She refused to listen, and I ended up leaving the medicine on the counter and walking out, never to return to this pharmacy again.
The best pilots I know are those that are continually aware that technology doesn’t eliminate human error and that it can even lead to new kinds of mistakes. They implement procedures as part of their training in crew resource management to catch and prevent mistakes, all the while knowing that the next slip-up can come at any minute. Pilots become masterful at managing multiple tasks and getting things done safely within competing constraints.
It occurs to me that just like my experience with the pharmacy, caregivers like me also have to juggle multiple tasks, some of which can be risky, especially when they are caring for individuals who are vulnerable because of their age or health.
Instead of looking at a caregiver as someone who will be less reliable because of their other obligations, it may be more appropriate to view caregivers as safety managers who can bring those same skills in error management to the nontechnical tasks involved in flying airplanes.
It’s time for employers in the aviation industry to recognize that some of the attributes seen as desirable in a pilot in the past, like single-minded competitive toughness, may not be advantageous flying today’s business jets and airliners. Today, strength of character is often a more important quality in a captain than physical strength, especially when you consider the types of stressors that are prevalent in the industry since 9/11 and a pandemic changed the risks.
When I got my multi-engine rating in a Piper Apache, I had to put both of my feet on the rudder pedal of the good engine to maintain control. Now a broken finger may be more of an impediment to moving the stick in an Airbus, and a captain could be faced with the task of finding diapers for her youngest passengers thanks to an airspace shutdown because of a terrorist attack. When diversions are more often due to a mental health issue in a passenger than a mechanical problem, the skills and experiences that caregivers who are pilots bring to the flight deck should make hiring managers take notice.
Shirley Phillips, Ph.D., is a Professor of Aeronautical Science at Southern New Hampshire University, Science Writer, Researcher and Airline Transport Rated Pilot/Instructor. She is an industry expert on human factors in aviation and is a published author.
留言