I invited Trevor to write a blog about the airline industry. Aviation, safety, human factors and crew resource management have taken centre stage in health care. My discussions with Trevor unveiled a dimension that I do not believe has been considered or given enough airtime – no pun intended. Trevor attributes the culture change in the aviation down to the realisation that training people by instruction was no longer appropriate and that the industry had to facilitate people to able to fly – the new terms are coaching, mentoring, reflection and self-actualisation. He closes his blog with a particularly important point.
Consider the 'person-specification' of your raw recruit. Airlines no longer look for pilots to fly their aircraft. They seek team players and teach them to fly.
I believe this applies to surgical training. We should no longer be looking for people who can operate but we should be seeking team players, teach them to operate and to adhere to standard operating protocols. We will start functioning as teams and engender respect. I believe we will then achieve a level of quality that to date has eluded us because many believe their way is the best way - at present we are herding cats.
Blog by Trevor Dale
It has long been the case, in many situations, that students and trainees need something of the chameleon in the genes. One trainer wants it done this way and another has an opposing view. This was certainly the way I progressed through basic flight training and the first 15 years of commercial flying.
It is worth spelling out that commercial aviation has a high penalty element for failure. It can of course terminate in death of self and others. Thankfully not all professions involve the first of those.
There is something frankly ironic, and for many quite stressful, about passing through a 'terminal' building at the airport. However, data suggests that flying is far the safest form of transport and so far, I have managed to obey the simple maxim of flight safety. Keep the numbers of landings exactly matching the take-offs.
When it comes to pretty much any profession, consider what the client, the ultimate employer, desires. A standard product in terms of skills but retaining their own individual personality. No one, outside of HR departments, wants identical clones with robotic reactions simply because people are all different. Passengers and crew colleagues vary as do medical colleagues and patients. In aviation, experience tells us that standardised procedures are essential to underpin the everyday variation in location, weather conditions and technical details. It rather helps if you're hurling 400 tons of metal full of passengers and fuel into the sky if you have a fairly firm idea what your colleague is doing now and hopefully, going to do next. The same thing seems reasonable to expect in health and social care, especially surgery. This is why briefings or 'huddles' are so crucial. A sharing of situational awareness to all present and potentially involved in the ensuing action. Surprises don't work out well in safety-critical professions. Although many believe that airline flying is all about pushing a couple of buttons and the automatics do the rest, it is in reality anything but. As we all know, weather can change significantly and little things like how long the runway is can make a huge difference.
My early experiences of receiving training to fly varied little in fact, but then it is pretty basic. Pull back on the stick and the houses get smaller, push forward and they get bigger. Push the stick to either side and the houses go upside down. However, keep pulling back on the stick and suddenly the houses can start getting dramatically bigger. Once one progresses through to more advanced flying, such as on instruments, in cloud or at night there is more room for interpretation. But we all had to achieve very strict parameters in flying precise accurate standard procedures in order to graduate and be let loose on an unsuspecting public. Nowadays this encompasses professional behaviour as well.
At flying college, I had the misfortune to have one particular instructor who had a laid-back attitude to calculating the approach and landing speed, which is weight-dependent in normal conditions. His was a 'that's near enough for what we need' approach. I came unstuck when taking my flight check from another examiner. I had an instructor change, fortunately, after that. I could have been chopped (removed from the course) but must somehow have had enough else in my favour, proving that you can, occasionally fool some of the people. Almost all the instructors had a military background. Some were great, some more stand-offish. Friendliness and professionalism are a terrific blend, especially in professions where skill and judgement in keeping self and others safe are called for. Confidence without arrogance is the ultimate aim and role-modelling is essential. What I now recognise as authenticity, integrity and empathy.
In the 1980's the realisation that attributing accidents to 'pilot error' was simply not enough. Airliners full of people were crashing at the rate of 1 per month on average. Crew Resource Management became the hot topic on the back of NASA-funded research into behaviour on the flight deck. From this came the initial training concept of raising flight crew awareness of effective and ineffective safety behaviour. What had been accepted as reasonable authoritarian hierarchy was now recognised as unhelpful and unsafe.
Analysis of the flight data and cockpit voice recorders revealed that most accidents occurred when the Captain was the pilot flying and the junior pilot was monitoring and supporting. Clearly change was essential. However, this had to be handled delicately without taking away the Command authority and responsibility. And so, it morphed into entirely new crew roles. In many airlines the standard procedure when in an emergency situation, became for the Captain to hand the flying of the aircraft to the co-pilot, thus freeing up the captain to think, manage, communicate and moreover exercise his or her judgement and experience. What was suddenly recognised was that if the co-pilot controlled the flight path, the Captain had spare capacity to think logically and monitor the evolving situation. The concept is known as Situation Control. In essence it is a coping strategy to trap and avoid the potential for stress overload in a crisis – fight, flight or freeze.
Enhancing awareness in break-out discussions of aircraft accident case studies is one thing. How does that translate into a real-World performance? What was needed was a thorough transformation of training and regular checks. Every year flight crew undergo six-monthly refresher training and checks in a simulator and another check on a regular passenger-carrying flight, known as a Route Check. Failure on any of these means instant grounding until a satisfactory performance on another day or ultimately dismissal if the pilot fails to meet the required standard. Aviation simulators have evolved into very hi-fidelity replications of reality. To some extent 'G' forces can be experienced though not totally, but the pilot can be fooled into thinking they are really flying and more to the point, about to die if or when they make some mistakes. The argument that "I wouldn't have done that in the Real World" simply doesn't stack up.
But to make the most of this training involves transforming the trainers from their previous stereotype of Instructors to facilitators. The time for instruction is when someone simply doesn't know. It is an input of new knowledge. But when one is building on existing knowledge and experience, as is the case with behaviour, then a drawing out of ideas, building on one's own experience is more successful. The fundamental issue is that nobody reacts well to being told how to behave. For it to be a sustainable change it needs to be coaxed out on a voyage of self-reflection, self-awareness and self-actualisation.2 That changes the Instructor to a mentor and coaching role. In the current world the trainer now has to embody Evidence-Based Training3 into every session. Observing, analysing and designing personal challenges for each individual trainee. Then offering and accepting feedback in a calm, factual method. This now has broadened into including cognitive and behavioural skills alongside the obvious technical skills. This was an enormous challenge for many even experienced instructors who struggled to comprehend the additions. But it became apparent that many instructors could not adapt and had to be removed from their roles. Many had arrived in their exalted position without having demonstrated and talent and now were found wanting.
We designed, developed and delivered an entirely new course which focused on the true role of the trainer and adult learning methodologies. The course was 5 days initially of theory and practice, modelling everything we were training. It was continuously assessable and not everyone graduated successfully. It is known as the Core Course and is mandated in over 43 countries. The impetus was from the Civil Aviation Authority, the single safety regulator in the UK, mandating Human Factors training and assessment alongside the technical skills from 1995. Other countries were doing the same or similar and it resulted in a Pan-European research program1 to define those essential Non-Technical Skills. The further development of ANTS4(Anaesthetic Non-Technical Skills) and subsequent NOTSS and SPLINTS for surgeons and scrub teams all evolved out of this original work.
The graduate of the Core Course would understand the key concepts of safe flight deck performance, be able to brief crew before they embarked on a real or simulated training session, be able to observe both technical and non-technical skills throughout the subsequent session, analyse them and lead a facilitated discussion post-hoc. A key part would also be the training report as written up afterwards which had of course, to be truthful, accurate and agreed, ideally with the trainees. We developed a simple format of Commentary - what happened; Appraisal – did it meet the required standard; Pointers – what could the trainee do differently and also what could they continue to do, in future.
The final piece in the jigsaw is, of course, standardisation of the trainers and this is regularly achieved by 'Training Standardisation Captains' who check the trainers every 24 months. They in turn are standardised regularly by external examiners from the regulator.
However, there is one other basic change that resulted from the whole movement into human factors in aviation. Certain other professions where safety performance is a crucial aspect could benefit. Consider the 'person-specification' of your raw recruit. Airlines no longer look for pilots to fly their aircraft. They seek team players and teach them to fly.
About the author:
Trevor Dale FRAeS, MRCPS(Glas)(Honorary) MCIEHF
Trevor Dale was an airline pilot from 1971 to 2005 and became a Training Captain flying Boeing 747's. Trevor began introducing human factors training to healthcare professionals in 2002 with paediatric cardiac surgery and now continues to do so across the entire spectrum including surgery, ICU, anaesthesia, maternity, mental health and community teams.
Trevor has been active in development of research and training initiatives in healthcare, aviation and other safety-related industries including nuclear power generation.
His passion is to help professionals develop and maintain their full range of skills, both technical and non-technical. He is working to introduce human factors implementation into child protection social work.