Health, Medicine, and Human Error

Jon Stuart, Ph.D., manager of Human Performance and Macro Analysis
Transportation Safety Board of Canada
Presentation to Queen's University, 27 August 2012

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Speaking notes

Slide 1: Title page

The purpose of this presentation is threefold: to provide you with insights as to how the TSB investigates for error (which you will cover in your course, focussing on medical errors); to describe how health and medical issues can lead to error; and to provide an opportunity to discuss how the health of medical practitioners may affect the likelihood of an error in their own work.

Slide 2: TSB mandate

The TSB's mandate is to advance transportation safety in the air, marine, rail and pipeline modes of transportation. We are not a court, and we do not assign fault or determine civil or criminal liability. We aren't a regulator, and we don't have powers of enforcement.

During an investigation, TSB investigators identify safety issues by assessing the technical, operational and human factors related to an occurrence. They then determine the unsafe acts and conditions, as well as any other underlying factors that might have an influence on safety. From there, they assess the risks and analyze the defences in place, as well as any other existing risk-control options.

The TSB issues Safety Advisories and Safety Information Letters to notify the industry and regulators as soon as possible when significant safety risks are found during an investigation. The Board issues recommendations to handle more difficult, systemic issues.

Slide 3: About the TSB

The Transportation Safety Board was formed in 1990 with the passing of the Canadian Transportation Accident Investigation and Safety Board Act. We conduct independent, expert investigations of selected marine, pipeline, rail and air occurrences.

A transportation occurrence can be an incident or accident. Incidents generally involve events such as engine failures or risks of collisions, whereas accidents are more serious, involving serious injury, loss of life or significant equipment damage. The reportable types of occurrences are defined for each transportation mode in the Transportation Safety Board Regulations.

We have approximately 230 employees across the country. The Board currently consists of 5 Board Members, including the Chair.

Slide 4: TSB investigations

The TSB receives notice of thousands of occurrences each year. Once an occurrence has been assessed, we make a determination—based on what we feel we can learn, and its potential to advance safety—to investigate, or not.

In 2011-12 we began a total of 60 investigations across the four modes: Marine, Pipeline, Rail and Air.

The next slides will serve as a reminder of the type of work that we do, highlighting some of the recent accidents in your region.

Slide 5: Collision with terrain

On the evening of January 7 2007, a Beech A100 King Air departed La Ronge, Saskatchewan, at 1930 central standard time under instrument flight rules to Sandy Bay, Saskatchewan. On board were two flight crew members and two emergency medical technicians. At 1948, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in to Runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain died of his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. Crew Resource Management (CRM) was identified as a factor in the occurrence, and afterward, the TSB recommended that: The Department of Transport require commercial air operators to provide contemporary CRM training for air taxi and commuter pilots.

Slide 6: Controlled flight into terrain

On November 16, 2008, an amphibious Grumman G-21A departed from the water aerodrome at the south terminal of the Vancouver International Airport, with one pilot and seven passengers. Approximately 19 minutes later, the aircraft crashed in dense fog on South Thormanby Island, about halfway between Vancouver and Powell River. The pilot and the six other passengers were fatally injured, and the aircraft was destroyed by impact and post-crash fire.

Pilot and operator decision making was identified as a factor in the occurrence.

Slide 7: Runway overrun

On August 2, 2005, an Air France Airbus overran runway 24L at Toronto's Pearson International Airport. One factor identified in the occurrence was pilot decision-making, especially in the face of rapidly changing weather conditions.

Slide 8: Concordia

On the afternoon of February 17, 2010, the sail-training yacht Concordia was knocked down and capsized after encountering a squall off the coast of Brazil. All 64 crew, faculty, and students abandoned the vessel into liferafts. They were rescued 2 days later by 2 merchant vessels and taken to Rio de Janeiro, Brazil.

Many human factors played a role in the occurrence.

Slide 9: Crossing accident (Brockville 2005)

On February 17, 2005, a young girl lost her life and a second received serious injuries while crossing double railway tracks near their school. The TSB determined that the two pedestrians stepped into the path of the eastward train while likely preoccupied with the passing of the westward train and their conversation. This type of accident is termed a "second-train collision." The TSB report shows that the proportion of this type of accident is increasing. The outcome of one of these accidents almost invariably results in a fatality. Without a pedestrian safety-specific intervention at multi-track crossings, the outcomes are not likely to change. Second train accidents are continuing, and children are especially at risk when faced with that deficiency.

Slide 10: Via Rail derailment (Burlington 2012)

On the afternoon of February 26, 2012, VIA Rail passenger train 92, en route from Niagara Falls to Toronto, entered the crossover in Burlington and derailed the locomotive and 5 coaches. The locomotive struck a building after it derailed and was totally destroyed. Many passengers were injured, and the 3 crew members in the cab of the locomotive were fatally injured.

TSB investigators examined the data from the locomotive event recorder (the "black box"), and confirmed that the train entered the crossover from track 2 to track 3 at approximately 67 mph. The maximum authorized speed at that crossover is 15 mph.

Slide 11: How we work

The TSB follows a scientific, systematic approach to investigations that is publically available. We provide training to other government agencies and, in some cases, industry.

Slide 12: TSB's products

The TSB issues Safety Advisories and Safety Information Letters to notify the industry and regulators as soon as possible when significant safety risks are found during an investigation. The Board can also issue safety concerns. The Board reserves its formal recommendations to handle the more difficult, systemic issues.

Slide 13: TSB powers & authority

Unless the police/RCMP etc. is investigating a possible criminal occurrence, the CTAISB Act grants TSB investigators wide powers. Section 19 defines these powers, and lists a number of conditions under which an IIC may exercise authority. In particular, he or she is allowed to:

  • Enter or restrict access to the area;
  • Seize any wreckage/impound equipment;
  • Compel witness interviews;
  • Obtain search warrants, sometimes even over the phone; and
  • Require a medical examination or coroner's examination.

So, our investigators have fairly broad powers. However, our approach is to nonetheless work very cooperatively with the people on site.

Slide 14: Human performance

We look at a very wide range of human factors topics as they apply to transportation accidents. Our human factors investigators are specialists in their area of this science, and they work closely with the investigative team—the members of which provide expertise in the transportation topic. Our five experts cover the field through experience and, when necessary, bringing in external resources.

Slide 15: Health & transportation regulations

This is a broad overview of the related transportation regulations across the modes.

Slide 16: Health & human performance

These are the main aspects of the relationship between health and error. These aspects drive our investigative process.

Slide 17: Investigative approach

Using a systematic, scientific approach, and with the incorporation of medical experts into the team, we examine what can be known about the health as declared to the regulator, the health at the time of the accident, and the health as declared to other physicians. This may include examinations after the accident.

Slide 18: How do the gaps occur?

These are the main areas that have repeatedly emerged in recent investigations: the deficiencies that have led to errors or unsafe conditions.

Slide 19: Crossing accident (Edson, 2005)

On 31 January 2005, a VIA Rail passenger train was struck by a southbound logging truck at the public crossing, Mile 92.26 of the Canadian National Edson Subdivision.

The driver was diagnosed with diabetes in 1992. He was prescribed oral medication and advised to use diet to control his blood sugar levels. Medical records indicated that the driver neither took his medication regularly nor tested his blood sugar levels regularly and that he often had high blood sugar levels. He had not taken his medication during the week before the accident nor reportedly for the last six months.

The driver did not eat breakfast on the day of the accident and ate a high-carbohydrate lunch within an hour before the accident. The air ambulance team took a blood sample immediately after the accident, and it was tested upon arrival at the hospital. The test showed a high blood sugar level. The driver's blood sugar levels remained high and uncontrolled during his recovery time in hospital.

The most significant symptoms of hyperglycaemia are blurred vision, reduced cognitive performance, fatigue, and dehydration. Changes in vision can degrade the distance at which a person can focus by as much as a factor of three. Any of these impairments can reduce driving performance.

Slide 20: Edson report findings

Here are some of the report's findings.

Slide 21: Edson report findings (continued)

Here are more of the report's findings.

Slide 22: River Rouge (Winnipeg, 2010)

On 29 July 2010, at approximately 1030, Central Daylight Time, the passenger vessel River Rouge with 71 passengers and crew on board ran aground in the Quarry Rapids on the Red River, north of Winnipeg.

Slide 23: River Rouge report findings

Here are two findings from that report.

Slide 24: Loss of control, CFIT (Miramichi, 2010)

On April 23, 2010, a Grumman TBM-3E Avenger fire-fighting aircraft departed Miramichi Airport for a practice water drop. Two minutes after departure, the aircraft collided with the ground just south of the airport. The aircraft was destroyed and the pilot was found deceased. Medical examination determined that the pilot had suffered a fatal heart attack prior to the aircraft impacting the ground.

The next three slides show some of the findings from that report.

Slide 25: Water bomber report findings

Slide 26: Water bomber report findings (continued)

Slide 27: Water bomber report findings (continued)

Slide 28: Via Rail derailment (St. Charles, 2010)

On 25 February 2010, at approximately 0425 Eastern Standard Time, VIA Rail Canada Inc. train No. 15, proceeding westward from Halifax, Nova Scotia, to Montréal, Quebec, entered the siding at Mile 100.78 of the Canadian National Montmagny Subdivision in the municipality of Saint-Charles-de-Bellechasse, Quebec, at about 64 mph and derailed 2 locomotives and 6 passenger cars. Two locomotive engineers and 5 passengers were injured.

The next two slides show some of the findings from that report.

Slide 29: St. Charles report findings

Slide 30: St. Charles report findings (continued)

Slide 31: How do the gaps occur? (Conclusions)

So, to review, these are the main areas that have repeatedly emerged in recent investigations—the deficiencies that have led to errors or unsafe conditions. What commonalities do you see with how you investigate and how these factors may play out in the health industry?

Slide 32: End