Lessons for Surgeons in the Final Moments of Air France Flight 447

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• 作者：Aneel Bhangu (1)
  Sonia Bhangu (2)
  James Stevenson (3)
  Douglas M. Bowley (4)
  
• 刊名：World Journal of Surgery
• 出版年：2013
• 出版时间：June 2013
• 年：2013
• 卷：37
• 期：6
• 页码：1185-1192
• 全文大小：442KB
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• 作者单位：Aneel Bhangu (1)
  Sonia Bhangu (2)
  James Stevenson (3)
  Douglas M. Bowley (4)
  
  1. General Surgery Registrar, West Midlands Deanery, Birmingham, United Kingdom
  2. Anaesthetics and Critical Care Registrar, East Midlands Deanery, Nottingham, United Kingdom
  3. Pilot and Airline Pilot Instructor, Flight Training Europe, Jerez de la Frontera, Spain
  4. Department of Surgery, Royal Centre for Defence Medicine, Birmingham, United Kingdom
  
• ISSN：1432-2323

文摘

Background All surgeons make mistakes, and learning from critical incidents may help improve performance. The present study aimed to highlight lessons for surgeons from analysis of the final moments of Air France Flight 447. All of the authors work in teams and situations where safety, technical performance, and non-technical skills are critical. This review was born out of discussions regarding the events of Flight 447; specifically, whether the airline disaster was relevant to their work, and whether they could learn anything from it. Methods The study is based on review of the crash reports of Flight 447, which lost flight speed indication after formation of ice prevented air from entering flight speed indicators during a storm. Following a subsequent stall, the aircraft fell at a rate of >10,000?feet/min until it crashed into the Atlantic Ocean, killing 228 passengers and crew. Results There were errors in decision making, reasoning, communication, and teamwork. Such non-technical skills failures have been recognized previously and can be addressed by existing non-technical skills training. A reliance on autopilot meant that the pilots were unfamiliar with high-altitude flying when the autopilot is disengaged. They were unprepared for and affected by such a sudden and serious problem; an event called “surprise and startle-by the accident investigation. The absence of the senior pilot (who was on a scheduled break) in the critical final minutes slowed error recognition and recovery. Conclusions Unintended consequences of modern safety strategies may be under-recognized and can lead to adverse events. Both simulation-based and non-simulation–based training should include “surprise and startle-events beyond the scenarios trainees might expect. Likewise, in the face of increasing reliance on modern technology, surgeons should ensure that they would be able to perform procedures in the absence of such technologies. Specific training may improve surgeons-non-technical skills, and recognition of such skills could also be used to help select future surgeons.