German airliner crash: A system error with a system solution?

From the Associated Press: Airlines around the world on Thursday began requiring two crew members to always be present in the cockpit, after details emerged that the co-pilot of Germanwings Flight 9525 had apparently locked himself in the cockpit and deliberately crashed the plane into the mountains below.

This represents an organization's typical response to a problem. The crash, which by all accounts was caused by a single deranged individual, has been perceived as the result of a “system error” and will be dealt with as such.

The idea that a flight attendant going into the cockpit whenever one of the pilots has to pee will prevent anything seems a bit absurd to me. How is a 5’2” 120 pound female flight attendant supposed to stop a 6’3” 210 pound pilot who is hell-bent on committing suicide by airplane?

When I tweeted a similar thought yesterday, someone suggested that she could simply sound an alarm and unlock the cockpit door. I suppose that’s true as long as the crazed pilot does not punch her in the face and knock her out or shoot her first.

9-year-old boy flies to Vegas without a ticket. System error or human error?

Last week, a 9-year-old boy managed to fly from Minneapolis to Las Vegas by himself without a ticket on Delta Airlines.

According to a CNN report, Delta is reviewing its "policies and procedures to make sure something like this does not happen again." This is the predictable response by most organizations when a screw-up occurs.

Do you think this was a system error or a human error?

I favor the latter. And the errors weren't confined only to Delta employees.

How many people had to have not followed established procedures for the child to have pulled this off?

At most airports, you can't even enter the security line without showing your boarding pass and ID. Children under 18 are not required to carry identification, but someone from the TSA had to have overlooked the fact that the boy had no boarding pass to scribble on.

Another possible check might have occurred as he passed through the metal detector by himself.

At the gate when boarding starts, an agent either marks each boarding pass or scans its bar code to tally the number of passengers on board. Obviously, the boy didn't have a pass so that did not happen.

Once he got on the plane, he had to have picked a seat at random. He would not have known which seats were unassigned. It is highly likely that he had to change seats at least once or twice. Again no one noticed that he didn't have a boarding pass.

The story says the flight crew became suspicious when the plane was in the air. They eventually noticed that he was an accompanied minor that they had not been made aware of.

What happened to the head count prior to closing the door? Most flights I've been on do not leave the gate until the flight attendants have walked through the cabin and counted the number of seated passengers.

Rather than a review of policies and procedures, the airline and the TSA should "counsel" the personnel involved in this event.

For other examples of human errors being thought of as system errors, type "system errors" in the search field of this blog.

TSA “Security Theater” becomes “Theater of the Absurd”

Three recent events serve as stark examples of the ridiculous level to which the Transportation Security Administration has sunk in its elaborate charade in the name of stopping terrorism.

Let’s start with a visual. This photo shows a TSA security pat down being conducted on an unlikely terrorist [Syriana notwithstanding], actor George Clooney. How silly can it get?

The next two episodes aren’t silly.

A 4-year-old child was fingered as possibly smuggling a gun to her grandmother, who needed a pat down after setting off the metal detector twice. The child had passed through the detector without incident. She went to where her grandmother was sitting and gave her a hug. Because of that, the child was identified as a “high-security” threat and frisked while sobbing hysterically. Remember, she had already gone through the metal detector. She was wearing leggings and a short-sleeved shirt. I suppose she could have been hiding a non-metallic gun in her rectum, but how big a gun could it have been? She was already inside the secure zone anyway. At least a body cavity search was not done.

The third case involves a 95-year-old retired Air Force officer and his 85-year-old friend, who both set off the metal detector due to joint replacements. Pat downs were deemed necessary. The man had $300.00 in bills and potentially incendiary Kleenex in his pocket and was asked to put the items in a bin so they could go through the X-ray scanner. After he was thoroughly searched, the money had gone missing. The entire scenario took over an hour and the pair nearly missed their flight. The TSA has yet to provide an explanation for what happened to the two travelers and their money. Oh, the security tapes were “too blurry” to be of use.

Is there no end to the madness? Couldn’t the personnel and resources wasted on these embarrassing incidents be put to better use?

Here's a similar rant of mine about the TSA from 18 months ago. Nothing has changed.

Acknowledgement: Thanks to @drval and @David_Dobbs for alerting me to the third case.

Questions on my mind

These things have been bothering me lately.

Why do you have to be at the airport two hours before an international flight? It shouldn’t take two hours to check to see if you’re on the “No Fly” list. Do the baggage handlers need that much time to steal the valuables from your suitcase?

Why can pilots, who sit right next to the avionics, use iPads on planes during takeoff and landing and I can’t? If iPads cause disruptions to sensitive airplane systems from Row 38, they must really wreak havoc from the pilot’s seat.

What does Microsoft do with the error reports they receive? I think the programmers at Microsoft sit around and laugh at the fools who send in these reports.

Why does the “Alternative Minimum Tax” sound like a good thing but actually is not so good? Having just paid it, the “minimum” part doesn’t seem so minimal to me.

Will the “Affordable Care Act” be affordable? I don’t think so.

Who made the rule that says a multicenter randomized controlled trial has to have a catchy acronym? If I see one more cutesy study acronym that is the result of a forced, artificially awkward series of words, I’m going to scream (or blog).

Why is it called “Meaningful Use”? Is it really meaningful? Or useful?

Why is gasoline the only item priced in 9/10 cent increments? I have no idea. It has been this way as long as I can remember.

How is it possible that someone could have a 2-inch long hair growing out of a nostril and not notice it?

Do you have any questions? Or answers?

What if doctors could charge like airlines?

Say you want to book a trip to Amsterdam in the next few months. You know that Delta flies there. You go to Delta’s web site to see what the fares are like.

Here is the first screen after you insert your dates.

Wow! $368.60 one way. Looks good, right?

Oh, but what’s this (arrow)? The total price is $901.60? They apparently did not have a smaller font for the total price figure.

So you click on that number and here’s what you see.

Whoop-de-damn-do, the base fare includes US tax. But what on earth are all the other charges? The “International Surcharge” is a mere $470.00. In medicine, this is called “unbundling.”

I wish doctors could charge like this. Of course, we can’t because our fees are heavily regulated and discounted by the government and other third party payers while expenses steadily rise.

But I can dream. Here is a sample bill.

In case you are wondering, for an appendectomy Medicare's average reimbursement to the surgeon is $586.00.

Aviation and Healthcare Compared in Review Article

In a paper* published ahead of print in the American Journal of Surgery (no abstract available), five cardiothoracic surgeons from the University of Miami compare both the similarities and differences between aviation and medicine.

Without simply reprinting the entire three pages of text and risking infringing on the AJS’s copyright, I can say that it is one of the most detailed and balanced analyses I have seen.

It includes some of the points I have made in previous blogs on the subject such as the heterogeneity of teams, simulators and systems in healthcare as compared to aviation and the lack of a true non-punitive culture regarding errors and near-errors in medicine.

The authors note that even checklists, which are relatively straightforward in aviation, can be much more complex in medicine. They also point out that protocols and practice guidelines are nether necessarily agreed upon or followed as commonly in medicine.

If you are interested in this subject, I urge you to obtain a copy of the paper from your medical library.

*Ricci, M et al. Is aviation a good model to study human errors in health care? Am J Surg. 2011 Sep 2. [Epub ahead of print]

Thanks to @DublinDoc for alerting me to this paper.

My previous blogs on this topic:

Surgeons vs. Pilots: There is no autopilot in the OR  
Surgeons are not pilots or long-distance truck drivers
Surgeons are not pilots
Patients are not airplanes