What Medicine can learn from Aviation

This entry is part 1 of 5 in the series The History of Thinking Medicine

So what should be done about the frighteningly high error-rate reported for Medicine? It’s difficult for Medicine. The reality is that a very young industry – the aviation industry – faced the same problems of error and solved them, radically altering its profession in the process.  In the 1970’s!  That’s more than forty years ago.  Yet Medicine, with its storied history of great, breakthrough thinkers, remains stuck.

So what is aviation’s story? The seeds of good thinking around accidents in aviation had actually been planted in the Second World War.  Before this time the approach was to select and trains humans to adapt to the machines (aircraft).  This paradigm seems to have come from a logical place – horses and, in particular, the cavalry.  When aircraft were invented and first used in combat in the First World War there was no precedent in the military, so a familiar mental model was used – cavalry – which is sort of understandable.  You’ve probably heard the expression knights of the air….  I can see it in my mind; a knight on a shining horse flying into battle. Early pilots thought of “riding” aircraft, and so the concept of learning to ride meant adapting yourself to the machine.  After all you can’t engineer horses to be different.  Horses just are horses.

The problem is that machines are not biological animals and they change a lot.

By the Second World War the technology became complex enough that a tipping point was reached and it overwhelmed the human pilots’ cognitive abilities.  And so crashes occurred, even amongst good pilots.  They were occurring because of poor aircraft design.

A US military figure, still largely unknown outside the circle of Human Factors engineers (and perhaps even largely within it) was tasked with figuring out why crashes were occurring.  A common problem was pilots pulling up the aircraft’s wheels just before landing and “belly landing” the aircraft unintentionally.  To put this in perspective there were over 2000 such incidents before this was figured out.  Two thousand!  That’s one heck of a lot of crashes before the problem was solved.  It turned out to be very simple, the landing gear lever was right next to the flap lever.  Flaps are what pilots are supposed to deploy on landing to provide more lift at low speeds and control the landing nicely.  What was happening was that whilst looking out the windows and lining up on the runway they were feeling for the flap lever with their hands, thinking they had it, and then pulling up the wheels instead.  The solution was tricky.  They couldn’t redesign aircraft retrospectively and put the levers in different places.

So a very simple but thoughtful solution was found.

The landing gear lever was topped with a round rubber ball, which the brain associates with tyres and wheels.  And, of course, the flap lever was metal – because flaps are metal – and it was a triangular shape which tests showed to be the best.  So by touch the pilots now got instant feedback as to which lever they were holding.  The wheels up accidents on landing immediately stopped.

This story from a sister industry shows exactly the level of awareness that had evolved around how human beings think.  

It ushered in the discipline of Human Factors in Design, or Cognitive Ergonomics if you like and started a complete about-face in paradigm.  Now aircraft were designed for humans and everything to do with them was built and shaped to work with human brains, it was no longer the other way around.  In the last forty plus years the field has raced ahead and transport, the military, shipping, nuclear power plants and a few others have adopted the lessons.  Medicine is now miles behind the rest…

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