"Secrets and Safety Don’t Mix"
J. Randolph Babbitt, Orlando, FL
October 21, 2009
Remarks as prepared for delivery.
Good morning, and thank you, Ed [Bolen], for the invitation.
I just got back from Osaka and Beijing on Friday, and for good measure threw in a 24-hour trip to and from Las Vegas to speak to some FAA managers yesterday. What I’m saying is that I’ve had a lot of time — about 44 hours just on airplanes during the last nine days — to think about NBAA and what to say to NBAA. I’d like to make two pitches: one for SMS, the second for professionalism.
Let me begin the discussion about SMS with a discussion about anesthesia. Over the years, anesthesia had the rep for being the stuff of medical misdeeds. What was created to put the patient to sleep — or at least render him oblivious to pain — instead became the subject of intense scrutiny because of operating room errors. When a mistake was made, and many a mistake was indeed made, it often proved fatal. It’s not surprising. There was a time when ether was used. While you’re thinking, “Thank God I wasn’t around for that,” I regret to inform you that ether was used as recently as 35 years ago. Everyone in this room knows that ether is about a half-a-spark away from a fire, and fire is generally frowned upon in the OR.
The trend kept going in the wrong direction. As mistakes were made, more and more people died on the table, and more and more families took their story to the courts. Settlements were reached. Files were sealed. What happened? Who knew?
If you found yourself anywhere in the chain of causation, real or perceived, get ready for a grim game of negligence hot potato. Just the kind of tag-you’re-it that gets people even more defensive.
The problem was clear; the solution evasive. If the anesthesiologist said, “This is what happened when I did X,” he was opening up the potential for a medical malpractice lawsuit. Because of the settlements being sealed, no one was talking. Because these were secrets kept at the order of the court, chances were good that they were going to stay that way. It’s hard to believe, but 25 years ago, very little actually was known about the people who died or were injured while under anesthesia. Even harder to believe: there wasn’t a single data base.
Finally, a group of anesthesiologists formed the Anesthesia Patient Safety Foundation. It was a stand-alone organization solely devoted to patient safety. Instead of fearing that it was a gimmick by medical suppliers to sell equipment or by doctors to point the finger of blame in another direction, an insurance company and a hospital agreed to participate.
Step one was to create a data base and fill it. While redacting privacy data, they pored through case after case, and the gold was in there.
In one string of cases, a filter that screened harmful gas from the patient would dry out over the weekend when the operating room went unused, thus rendering the filter useless for Monday surgeries, thus jeopardizing the patients. But no one connected the dots.
In other cases, the anesthesiologists simply stuck the tube down the wrong pipe. And the patient would die. But no one knew how often that happened, either.
But in the course of studying these issues, new procedures were developed. New equipment, albeit expensive, was purchased. And the mistakes grew fewer and further between. Premiums dropped, and more importantly, patient deaths dropped dramatically.
The information was always there, it’s just that people wouldn’t share it for one reason or another. Some were afraid of punitive action. Others thought it best to keep silent. But when someone finally got the bright idea that there was gold to be had on the other side of the curtain when someone finally got the courage to convince his colleagues that this was worth the time, money, and self-examination it took, the result was in lives saved.
There’s a line in The Rime of the Ancient Mariner that says, “Water water everywhere, and not a drop to drink.” That’s us in aviation. There’s data all over the place, but in too many instances, we can’t get to it. In order to ratchet up the level of safety, to move to the next level, Safety Management Systems are the only option. When you have as few accidents as we do, it’s difficult to spot a trend with a chart that has only three data points on it. SMS is the solution. SMS doesn’t wait for accidents. Now forensics has brought us to the place where we’re exceedingly safe. We’ve nearly eliminated the common causes of aviation accidents. But safety management systems will allow us to spot precursors. That’s the data. That’s the gold. That’s where we need to dig.
It’s only when people know that they can raise their hand — “There’s a problem here” — that’s when we’re going to make the big leaps forward in safety. If you have a situation where someone is punished for raising a flag, all you’ve done is encourage silence. When you sweep things under the rug, accidents happen, equipment is lost, people die.
We must avoid the temptation to cut corners because the economy is tight. I know the flight departments in this room are feeling the pinch. But the stock market should never have a bearing on whether or not people speak up. Do not get to the place where you’re thinking, “Oh, I know all the items on the checklist; we don’t need to read it.” When you skip a step here and there, bad things will happen. And when they do, you can’t be surprised.
I’m not here to criticize. My words are a reminder that we must step up. When it comes to safety, the status quo is never acceptable. Since 2002, corporate aviation has averaged a fatal accident only one in every 3.5 million hours. That is a superb record, but it’s a watermark. We need to continue to push for safety.
Safety records like that start with the professionals in this room. So, let’s do a mental check ride that applies to pilot, crew and flight department. Are you reporting for duty rested and prepared? Are you continuously refreshing your knowledge? Are you rigorously following checklists and procedures? Do you discipline yourself to stay at least 10 miles ahead of the aircraft? Do you use quiet moments to make productive use of the time, something such as briefing, rechecking the FMS, or plan? Do you brief thoroughly and communicate clearly to ATC and your crew?
Do you fly with precision?
Do you push to a higher standard of professional flying? In that context, you should read “professional” and “disciplined” as meaning one and the same.
Here’s another thought: Do you expect the same from other pilots? When the moment strikes, are you careful not to let a teaching/mentoring situation slip by without addressing it?
Do you honestly provide feedback to your flying partners? Do you honestly seek feedback from your flying partner about your own performance?
Do you strive to look and act professional?
You’ve got to be running through this list of questions, or a list just like it, every day.
The fact of the matter is: we can’t regulate professionalism. I can’t make you be a mentor. We know that the best lessons of all usually come from someone who’s been there before. He or she takes the time to tell us why inspecting with our own two eyes is never a bad thing. When you think about the catastrophes like ValuJet, Tenerife or Buffalo, there’s a list of red flags where someone didn’t react appropriately. In any of these cases, professionalism and mentoring probably would have made a difference. It does add up.
That’s why I continue to stress the need for mentoring. If I close my eyes, I can still remember the glare from my first instructor when I did the wrong thing. But he always followed up with telling me about the right way. Aviation is a tough enough skill to come by as it is. It’s no place to learn through the school of hard knocks. We need strong professionals — the kind the NBAA is known for — to step forward and become mentors. If you’re already doing it, good. If you’re not, recognize that you have some valuable lessons tucked away that just might help someone someday do the right thing, at the right time, when no one is watching.
In closing, it’s clear that SMS will enable us to connect the dots with the data. Professionalism and mentoring will help us put it to good use. And bringing all of this full circle, the story about the anesthesiologists, the discussion of SMS, and the need for professionalism all share a common thread, and that thread is you. As safe as we are, we need to be safer still. We need to step up. And each of us, individually and collectively, needs to accept the responsibility for making it happen. Thank you.