In this episode Amir and Adam discuss three aviation accidents that parallel the Elaine Bromiley case.

• Human factors in medicine: As Captain Bromiley put it, this was not an individual failure. It was a system failure. It was a failure of human performance. In aviation, 75% of airline accidents are due to human factors rather than mechanical failure. 
• Eastern Airlines Flight 401 (1972)
  • Fixation-induced loss of situational awareness.
  • Troubleshooting a landing gear light indicator problem in the cockpit (one of the landing gear lights would not indicate the gear was down and locked).
  • The autopilot was engaged and the aircraft was flying over unlit terrain (the Florida everglades) at night.
  • One of the flight crew inadvertently bumped the control column which disengaged the autopilot.
  • Despite an altitude alert chime being audible on the Cockpit Voice Recorder (CVR), none of the crew responded to it.
  • The aircraft slowly descended and impacted terrain.
  • The landing gear was in fact down and locked and the failure of a single light bulb resulted in many fatalities.
• United Airlines Flight 173 (1978)
  • Fixation-induced loss of situational awareness leading to fuel exhaustion and crashing in Portland
  • Troubleshooting a landing gear light indication problem, similar to Eastern Airlines Flight 401
  • Again the light failed to indicate, but the gear was later found to be in a safe position
  • This time the Captain continued to circle to try to troubleshoot the problem and optimize the conditions for the emergency landing with a potentially unsafe landing gear.
  • Despite the First Officer (FO) and Flight Engineer (FE) attempting to tell the Captain that the aircraft was dangerously low on fuel, the Captain continued to take time to work the landing gear problem.
  • When the engines began to fail, the Captain was surprised that it was because of a lack of fuel.
• Air Florida Flight 90 (1982)
  • Poor crew coordination and lack of assertiveness / failure of leadership leading to a crash on departure in icing conditions.
  • The failure to engage the engine anti ice later led to a false indication in the cockpit instruments showing that the engines were developing sufficient thrust for takeoff when they weren’t.
  • The Captain ignored the First Officer’s repeated concerns about the amount of ice on the wings and whether the engines were developing sufficient power on takeoff.
• Just a Routine Operation (YouTube - 6 min)
• Just a Routine Operation (YouTube - 14 min)
• Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube - 23 min)
• Eastern Airline Flight 401  Mayday Fatal Distraction - S05E09 (YouTube)
• United Airlines Flight 173 - Mayday Focused on Failure  S12E08 (YouTube)
• Air Florida Flight 90 - Mayday Disaster on the Potomac - S13E04 (YouTube)
• ACCRAC Ep 325: The WISH Inventory and Well-Being in Anesthesiology with Drs. Higgins and Vinson (anesthesiologists take an outsized sense of responsibility for outcomes - at 5 min

Welcome to the Medical Safety Podcast where we aim to improve the safety of our healthcare system through the integration of human factors into medical incident investigation and proactive safety measures. This podcast is hosted by two Canadian anesthetists, Drs. Adam Shehata and Amir Hamid. In the inaugural episode, we take a look at the 2005 death of Elaine Bromiley and the lessons learned from it.

Elaine Bromiley

• • Healthy 37 year old woman for elective sinus surgery in the UK in 2005
  • Can’t Intubate Can’t Oxygenate
  • Experienced surgical team
  • Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal mask airway (LMA)
  • Several minutes went by, meanwhile a nurse brought in a cricothyroidotomy kit for surgical Front of Neck Access (FONA). The nurse announced the kit’s presence to the operating theatre but received no response.
  • After 40 minutes (20 without sufficient oxygenation), an airway was established with an LMA.
  • A nurse had arranged for an ICU bed and returned to the OR to tell the team, but received a look from the physicians as if to say, “What’s wrong? You’re overreacting.”
  • Elaine was taken to the recovery room and the surgical team continued on with the rest of the patients on the list.
  • The nurses in the recovery room were concerned that Elaine may have been having seizures and called the anesthetist, but he was busy with a patient in the OR and could not attend.
  • Eventually, Elaine was transferred with an LMA (as opposed to a secured airway) to another hospital for ICU care.
  • Having confirmed an unrecoverable anoxic brain injury due to the lack of oxygen on induction of anesthesia, Elaine was removed from life-sustaining therapy and allowed to die naturally.
• Martin Bromiley
  • Elaine’s husband, and father to their two young children, was also a UK airline pilot
  • He told the hospital that he would “wait for the report” which is what would have happened if Elaine had died on or near an airplane in the UK. The accident investigation board, an independent investigatory body, would have determined the causes and contributing factors and then published an anonymized report with recommendations on how to improve safety.
  • Mr. Bromiley was told that no such process existed in the UK
  • Martin commissioned just such a report “so others can learn”.
  • Importantly, Martin did not seek punishment. He specifically stated that the physicians and nurses that were in that room were intelligent, hard working, caring professionals. He did not blame them. He blamed the system. The system can be changed but first we need to know what happened and why.
• The report
  • A failure of leadership and communication which led to a fixation-induced loss of situational awareness
  • The physicians became fixated on intubating to the exclusion of other possibilities of providing oxygen (such as FONA).
  • They became so fixated that they did not respond to the nurses who later reported knowing what needed to happen but being unable to communicate it effectively.
• YouTube videos Martin Bromiley produced to improve patient safety:
  • Just a Routine Operation (6 min)
  • Just a Routine Operation (14 min)
  • Martin Bromiley: A patient’s perspective (March 16, 2018 - 23 min)

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