This document discusses lessons that can be learned from aviation safety and applied to other fields like healthcare. It highlights the importance of viewing accidents as systems failures rather than individual errors, and creating a culture of safety through open reporting, training on both technical and soft skills, and ensuring safety takes priority over economic or legal pressures. Procedures, simulation training, and learning from other industries can help develop the general competencies needed to handle unexpected situations safely.

1. New Perspectives in Patient Safety; Is the pilot a better doctor? Controversies in Obstetrics, Gynecology and Infertility, 2008 Nicklas Dahlstrom, Lund University School of Aviation

2. Human Error and Accidents - Then and Now Technology support increased safety - but creates new risks!

3. What have we learned about safety in aviation?

4. What have we learned about safety in aviation? … well, some about cooperation, team work and leadership!

5. What happened? British Midlands Flight 092

7. ” Operator Error”? Day 2: “ According to excerpts from the recorded conversation between the driver and the control station, Tomei (the driver) was apparently authorised to go through a red light in order to unblock rush-hour congestion.” Day 1: “ This eyewitness, Fabbio de Santes, who was on the second train, said it ran through a red signal before ploughing into the stationary train in front.”

9. Perception

10. Memory Consider limitations of short-term memory! Create routines which adhere to them!

12. Communication Over-clarity does not exist when it comes to safety! Communication should be clear and specific, also with colleagues you work with daily

13. Murphy’s law is wrong! Things that may go wrong actually has no negative consequences… … and we end up drawing the wrong conclusions. Why accidents?

14. Why accidents?

15. Drift towards Failure Unsafe acts of processes Safe acts and processes Drive for increased efficiency can lead to erosion of safety New norms, routines, procedures intended to increase efficiency Safe acts according to routines, procedures etc.

16. Hero-stories Accident-stories “ Stories” in a Safety Culture Increase Safety - Reporting

17. Increase safety - Training Crew Resource Management is the effective utilisation of all available resources (e.g. crew members, aeroplane, systems and supporting facilities) to achieve safe and efficient operation Recurrent and adapted to the organization

18. Increase safety - Training

19. Swissair 111 - In-flight Fire Nova Scotia, Canada September 2, 1998 Increase Safety - Procedures

20. Swissair 111 - In-flight Fire Nova Scotia, Canada September 2, 1998 Increase Safety - Procedures “ If smoke/fumes are not eliminated, land at nearest suitable airport.”

22. Procedures, Training and Simulation

23. Procedures, Training and Simulation

25. Safety, economy, law and technology

27. Thank you for your attention! E-mail: nicklas.dahlstrom@tfhs.lu.se