Ambulance controllers trying to respond to the 7/7 attacks worked in chaos amid a series of shortcomings, the inquests into the attacks have heard.
They include:
* Only one woman logged all the emergency calls and vital information was written on scraps of paper, it was revealed.
* Ambulance Service logger said: "I am not a trained typist, I use two fingers and a thumb."
* The employee in charge of updating the control room whiteboard could only reach halfway up it.
* Two of the people designated "crucial roles" at the start of the incident were not trained in the procedures for the so-called Gold Command - in overall control of the emergency.
* Staff transferring from their normal control room positions to the Gold disaster control room caused a delay because they had not logged off properly. That meant they were then unable to log on to the new system as calls from the four terror sites built up, causing a backlog.
* There were communications issues throughout. Radio channels were blocked and no feedback was coming in from ambulance bosses on the ground.
* There was so much information coming in that control room staff were unable to prioritise it effectively.
* Failed radio and mobile phone networks meant there were serious delays in dispatching paramedics to bomb sites.
Monday, February 28, 2011
Friday, February 25, 2011
No easy solutions for alarm fatigue
Article at Boston.com by Liz Kowalczyk on 14 February 2011
77 year old Madeline Warner died at UMass Memorial Medical Center in Worcester USA died after nurses failed to respond to an alarm that sounded for about 75 minutes, signalling that her heart monitor’s battery needed to be replaced, state investigators found.
The article explains the problems in hospitals with large numbers of alarms that personnel are required to respond to. The whole industry is finding it difficult to come up with a solution. Options include:
1. Improving monitor technology, to sharply decrease the number of false alarms, which some studies have shown exceed 85 percent. New machines would simultaneously sense multiple measures of a patient’s health to more accurately gauge whether a patient is really in crisis.
2. Hiring more nurses, and assigning some to do nothing but watch monitors for alarms.
3. Strengthening voluntary industry standards or federal rules for monitor design and use, such as requirements for how loud alarms should be, or how long monitors should delay sounding an alarm to ensure an apparent problem is real and reduce false alarms.
4. Implement new guidelines for doctors on when to order cardiac monitoring for patients, and how often they must recheck their orders. When technology is readily available doctors end up ordering it for patients who might not benefit. But persuading doctors to put significantly fewer patients on monitors will be a huge challenge, because monitors can be an important tool for alerting staff to problems.
The hospital has already made changes to reduce the likelihood of alarms being missed. Low-battery warnings now appear on the pager or cellphone of the patient’s nurse. If he or she does not respond within a minute, a page goes to all nurses on the unit — as do alarms for potential life-threatening changes in patients. Also, the hospital has replaced cheap $1 leads for the wires that run from a patient’s chest to the monitor with $14 leads that rarely fall off and significantly reducing “leads-off’’ alarms.
GE Healthcare, a monitor maker, is testing similar technology for intensive care units. The company said the new software significantly reduces the number of false heart rate alarms because it uses information from a variety of physiological signals to evaluate patients, rather than just cardiac information. At one hospital, “the technology resulted in an 89 percent reduction in false asystole alarms’’ (asystole refers to a state of no cardiac activity), compared with a traditional cardiac monitor, the company said in a written statement. But this approach is probably only likely to work in intensive care.
77 year old Madeline Warner died at UMass Memorial Medical Center in Worcester USA died after nurses failed to respond to an alarm that sounded for about 75 minutes, signalling that her heart monitor’s battery needed to be replaced, state investigators found.
The article explains the problems in hospitals with large numbers of alarms that personnel are required to respond to. The whole industry is finding it difficult to come up with a solution. Options include:
1. Improving monitor technology, to sharply decrease the number of false alarms, which some studies have shown exceed 85 percent. New machines would simultaneously sense multiple measures of a patient’s health to more accurately gauge whether a patient is really in crisis.
2. Hiring more nurses, and assigning some to do nothing but watch monitors for alarms.
3. Strengthening voluntary industry standards or federal rules for monitor design and use, such as requirements for how loud alarms should be, or how long monitors should delay sounding an alarm to ensure an apparent problem is real and reduce false alarms.
4. Implement new guidelines for doctors on when to order cardiac monitoring for patients, and how often they must recheck their orders. When technology is readily available doctors end up ordering it for patients who might not benefit. But persuading doctors to put significantly fewer patients on monitors will be a huge challenge, because monitors can be an important tool for alerting staff to problems.
The hospital has already made changes to reduce the likelihood of alarms being missed. Low-battery warnings now appear on the pager or cellphone of the patient’s nurse. If he or she does not respond within a minute, a page goes to all nurses on the unit — as do alarms for potential life-threatening changes in patients. Also, the hospital has replaced cheap $1 leads for the wires that run from a patient’s chest to the monitor with $14 leads that rarely fall off and significantly reducing “leads-off’’ alarms.
GE Healthcare, a monitor maker, is testing similar technology for intensive care units. The company said the new software significantly reduces the number of false heart rate alarms because it uses information from a variety of physiological signals to evaluate patients, rather than just cardiac information. At one hospital, “the technology resulted in an 89 percent reduction in false asystole alarms’’ (asystole refers to a state of no cardiac activity), compared with a traditional cardiac monitor, the company said in a written statement. But this approach is probably only likely to work in intensive care.
Mother dies after nurse makes error administering drug
Article from the Daily Mail 23 February 2011
In true Daily Mail style the story is hyped under the title "Mother-of-four dies after blundering nurse administers TEN times drug overdose"
80 year old Arsula Samson died on 14 March 2010 at Good Hope Hospital, Birmingham after she was given an overdose of deadly potassium chloride.
According to the inquest staff nurse Lisa Sparrow wrongly administered 50ml of the drug over half an hour instead of over five hours, the inquest heard.
Instead of pressing the 10ml per hour button, the nurse admitted tapping in 100ml per hour on the drug infusion pump.
Staff nurse Sparrow signed out the medication from the controlled drug stock cupboard with staff nurse Susan Smith, as two people were supposed to administer and check the drug together to avoid any errors under hospital policy.
But nurse Smith left nurse Sparrow to give the drug on her own when the error happened. The coroner said that nurse Sparrow's gross failure resulted in the overdose and was a direct cause for the death while a second failure was that nurse Smith did not oversee the drug being given.
Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death
Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death
Nurse Sparrow told the inquest she had not expected nurse Smith to watch her give the potassium as 'no-one ever did'.
An official Trust report said no error was found with the infusion pump and investigators ruled the death was due to 'individual, human error'.
A Trust action plan after the death saw new infusion pumps and software that reduce the risk of error brought into all wards, medical staff retrained and warned over the dangers of potassium chloride and advice on the importance of a second nurse witnessing medication being given.
Birmingham coroner Aidan Cotter gave a verdict of accidental death to which neglect contributed.
In true Daily Mail style the story is hyped under the title "Mother-of-four dies after blundering nurse administers TEN times drug overdose"
80 year old Arsula Samson died on 14 March 2010 at Good Hope Hospital, Birmingham after she was given an overdose of deadly potassium chloride.
According to the inquest staff nurse Lisa Sparrow wrongly administered 50ml of the drug over half an hour instead of over five hours, the inquest heard.
Instead of pressing the 10ml per hour button, the nurse admitted tapping in 100ml per hour on the drug infusion pump.
Staff nurse Sparrow signed out the medication from the controlled drug stock cupboard with staff nurse Susan Smith, as two people were supposed to administer and check the drug together to avoid any errors under hospital policy.
But nurse Smith left nurse Sparrow to give the drug on her own when the error happened. The coroner said that nurse Sparrow's gross failure resulted in the overdose and was a direct cause for the death while a second failure was that nurse Smith did not oversee the drug being given.
Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death
Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death
Nurse Sparrow told the inquest she had not expected nurse Smith to watch her give the potassium as 'no-one ever did'.
An official Trust report said no error was found with the infusion pump and investigators ruled the death was due to 'individual, human error'.
A Trust action plan after the death saw new infusion pumps and software that reduce the risk of error brought into all wards, medical staff retrained and warned over the dangers of potassium chloride and advice on the importance of a second nurse witnessing medication being given.
Birmingham coroner Aidan Cotter gave a verdict of accidental death to which neglect contributed.
Sunday, February 20, 2011
Vietnam boat sinking: Human error blamed, two arrested
BBC Website 20 February 2011
Human error was to blame for the sinking of a tourist boat in Vietnam which killed 12 people, including one Briton, Vietnamese police have said.
Quang Ninh police spokesman Le Thanh Binh said a valve that allowed water to come into the boat to cool the engine had been left open overnight.
Stuart McCormick, 30, from Irvine, Ayrshire, died with 11 holidaymakers and a Vietnamese guide in Halong Bay.
The vessel's captain and a crew member have been arrested.
The wooden boat was touring the Unesco World Heritage Site in Quang Ninh province when it went down.
Speaking to Associated Press news agency, Mr Binh said: "The initial police investigation showed that the man in charge of the boat engine forgot to close the valve that allowed water in to cool the engine before he, the captain and other crew went to bed."
The engine was turned off, preventing a pump from running to push the water out.
By the time the captain and crew woke to find the boat filled with water, it was too late and the vessel sank quickly, he said.
Human error was to blame for the sinking of a tourist boat in Vietnam which killed 12 people, including one Briton, Vietnamese police have said.
Quang Ninh police spokesman Le Thanh Binh said a valve that allowed water to come into the boat to cool the engine had been left open overnight.
Stuart McCormick, 30, from Irvine, Ayrshire, died with 11 holidaymakers and a Vietnamese guide in Halong Bay.
The vessel's captain and a crew member have been arrested.
The wooden boat was touring the Unesco World Heritage Site in Quang Ninh province when it went down.
Speaking to Associated Press news agency, Mr Binh said: "The initial police investigation showed that the man in charge of the boat engine forgot to close the valve that allowed water in to cool the engine before he, the captain and other crew went to bed."
The engine was turned off, preventing a pump from running to push the water out.
By the time the captain and crew woke to find the boat filled with water, it was too late and the vessel sank quickly, he said.
Thursday, February 17, 2011
Human factors performance indicators
Published by Energy Institute in 2010 and available from the EI Website
The report explores what performance indicators are and how they are used, and proposes a methodology for selecting human factors performance indicators for each of the HSE top 10 key human factors issues. The report also provides a list of example human factors performance indicators which are already being used by industry or which could potentially be used.
The report explores what performance indicators are and how they are used, and proposes a methodology for selecting human factors performance indicators for each of the HSE top 10 key human factors issues. The report also provides a list of example human factors performance indicators which are already being used by industry or which could potentially be used.
Sunday, February 06, 2011
Slug kills teen girl driver
Articles in The Sun and Express on 31 January 2011
Katie Dagley, 19, was killed in a head-on collision on a brige at Alvecote, near Tamworth, West Midlands.
The bridge was single track, with traffic lights to only allow vehicles to travel one way at a time. An investigation found that the traffic lights had malfunctioned 20 minutes before the crash. There was a trail across the circuit board and it had short-circuited it.
The driver of the, James Cope, 18, told how he saw Katie's car but did not have time to brake.
Katie Dagley, 19, was killed in a head-on collision on a brige at Alvecote, near Tamworth, West Midlands.
The bridge was single track, with traffic lights to only allow vehicles to travel one way at a time. An investigation found that the traffic lights had malfunctioned 20 minutes before the crash. There was a trail across the circuit board and it had short-circuited it.
The driver of the, James Cope, 18, told how he saw Katie's car but did not have time to brake.
Friday, February 04, 2011
Proposed regulation by FAA closes human factors loophole
Article on Flightglobal website by John Croft 2 February 2011
The US Federal Aviation Authority (FAA) is proposing to close a human factors loophole in the regulations governing the certification of transport category aircraft with increasingly advanced-technology integrated flight decks.
In a notice of proposed rulemaking (NPRM) to be issued on 3 February, the agency calls for creating more explicit requirements for "design attributes" related to "managing and avoiding" pilot errors, including being able to detect and recover from keypad errors.
"In hindsight of analysis of accidents, incidents or other events of interest, these deviations might include: an inappropriate action, a difference for what is expected in a procedure, a mistaken decision, a slip of the fingers in typing, an omission of some kind, and many other examples," says the agency in the NPRM.
The US Federal Aviation Authority (FAA) is proposing to close a human factors loophole in the regulations governing the certification of transport category aircraft with increasingly advanced-technology integrated flight decks.
In a notice of proposed rulemaking (NPRM) to be issued on 3 February, the agency calls for creating more explicit requirements for "design attributes" related to "managing and avoiding" pilot errors, including being able to detect and recover from keypad errors.
"In hindsight of analysis of accidents, incidents or other events of interest, these deviations might include: an inappropriate action, a difference for what is expected in a procedure, a mistaken decision, a slip of the fingers in typing, an omission of some kind, and many other examples," says the agency in the NPRM.
Thursday, February 03, 2011
Safety on the Front Lines
Article in Aviation Week by Heather Baldwin on 1 February 2011
I'm a bit surprised that the article is written as if human factors is a new idea in the aviation industry, but it does give some good examples of problems. For example taken from a survey of maintenance managers:
* More than half think their employees complete jobs despite the non-availability of specified tools or equipment.
* 16% said they believe their employees have signed off for uncompleted work due to limited time or resources.
* One in 10 managers admitted their line supervisors would approve a mechanic’s actions if he didn’t follow procedures in order to get an aircraft out.
* 26% of technicians believe that their immediate bosses would approve of their actions if they did not follow procedures in order to speed up their work on an aircraft
"An error is rarely the sole fault of an individual; rather, it often is driven by organizational pressures, expectations and unwritten policies."
A technician was fired because, in violation of regulations, he walked an aircraft back solo one night and damaged it. On the surface, it might appear to be the poor judgment of a single individual. In fact, the organization where this occurred had cut back so severely due to cost pressures that it didn’t have the manpower for two wing walkers on the midnight shift. Consequently, under pressure to get the work done, technicians routinely moved airplanes with one walker.
"Maintenance errors are the consequences of the processes, decisions and culture established by the organization."
JetBlue Airways has many safety initiatives including the "Pocket Session" that requires senior leaders to get out routinely and meet with front-line workers. No one is ever punished for bringing forward a safety concern, employees are encouraged and expected to submit safety reports on all potentially unsafe situations they encounter. Examples of unsafe situations reported include "ramp lighting" and "running engines with passengers onboard." JetBlue says its "injuries, ground damages and other measures, has been better year over year almost every year since we’ve been in operation." "From 2009 to 2010, the injury rate for Tech Ops dropped 83%."
I'm slightly concerned that the article is referring to reduced injury rates at JetBlue with no consideration of whether this is relevant to flight safety.
I'm a bit surprised that the article is written as if human factors is a new idea in the aviation industry, but it does give some good examples of problems. For example taken from a survey of maintenance managers:
* More than half think their employees complete jobs despite the non-availability of specified tools or equipment.
* 16% said they believe their employees have signed off for uncompleted work due to limited time or resources.
* One in 10 managers admitted their line supervisors would approve a mechanic’s actions if he didn’t follow procedures in order to get an aircraft out.
* 26% of technicians believe that their immediate bosses would approve of their actions if they did not follow procedures in order to speed up their work on an aircraft
"An error is rarely the sole fault of an individual; rather, it often is driven by organizational pressures, expectations and unwritten policies."
A technician was fired because, in violation of regulations, he walked an aircraft back solo one night and damaged it. On the surface, it might appear to be the poor judgment of a single individual. In fact, the organization where this occurred had cut back so severely due to cost pressures that it didn’t have the manpower for two wing walkers on the midnight shift. Consequently, under pressure to get the work done, technicians routinely moved airplanes with one walker.
"Maintenance errors are the consequences of the processes, decisions and culture established by the organization."
JetBlue Airways has many safety initiatives including the "Pocket Session" that requires senior leaders to get out routinely and meet with front-line workers. No one is ever punished for bringing forward a safety concern, employees are encouraged and expected to submit safety reports on all potentially unsafe situations they encounter. Examples of unsafe situations reported include "ramp lighting" and "running engines with passengers onboard." JetBlue says its "injuries, ground damages and other measures, has been better year over year almost every year since we’ve been in operation." "From 2009 to 2010, the injury rate for Tech Ops dropped 83%."
I'm slightly concerned that the article is referring to reduced injury rates at JetBlue with no consideration of whether this is relevant to flight safety.
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