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Hello, good evening. Good afternoon. Good day. Good morning. Wherever you are in the world, we have a message from the flight deck that there are technical problems with the sound. This should not take long to sort out. And the captain assures us we should have pushed back from our stand in two or three minutes. In the meantime, I'd like to introduce the captain for this evening. Firstly, my name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom. The past director, the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh, and a visiting professor at Imperial College to those who are joining the Black Belt Academy for the first time this evening. Thank you very much. Indeed. And for the 3297 followers on Facebook and the 584 on Instagram. Thank you too. We've interspersed our discussion's about basic surgical skills with keynote speakers and I am delighted this evening to welcome a friend, a colleague. Now, Danny now is a qualified doctor from Trinity College, Dublin in 1993 he trained as a surgeon in Belfast and received his fellowship with the Royal College of Surgeons of Ireland in 1997. Here's a trainee cardiothoracic surgeon working as a S H O in the Royal Victoria Hospital before returning to Dublin, where he worked as a registrar in the National Cardiac Surgical Unit. And now and I cross paths back in 1999 we'll explore this, but he subsequently retrained as an airline pilot with air lingus in 1999 and combined aviation with working as an emergency doctor for six weeks years before focusing on his career as a pilot. After operating as a copilot of both European and transatlantic fleets. He qualified as a captain in 2010 is currently working out of Dublin, but I think recently just moved to Manchester for the Airbus 330 Trans Atlantic fleet. I must apologize to the audience who are discerning about the interior of cockpits. The photograph was not a 330 but is now pointed out a 380 Airbus in 2011, he formed the framework of health, a company providing aviation style safety training modified specifically for healthcare. And he draws on his 35 years experience as both a surgeon and a pilot. And this project aims to share aviation safety management system with healthcare in order to address those issues of adverse events, usually caused by systemic faults but often blamed on the last individual to have touched the ball. Now aims to encourage healthcare to adopt a just culture and embed as systemic human factors approach and empower patient's in their families to speak up as part of the crew. He's a regular speaker at conferences at both national and international level and had a TED talk in 2016, outlining his message and he's just about to bring out a book. You can preorder now as it's available in May is called whoops, why things go wrong. And now thank you very much indeed for joining the Black Belt Academy this evening. Thank you, David. Thanks for having me again. An absolute pleasure. Now, what is unique about your position? We have compared contrast the airline industry with surgery previously, but I think you must be the only person flying in the skies to have been in the operating theater training as a surgeon. You left cardiac surgery to become a pilot and perhaps you could tell the audience why that is the case. Well, first of all, there's not many of us, but I'm not unique. Air lingus actually took on three surgeons the month that I joined. Really? Where's myself an orthopedic registrar and a cardiothoracic S H O and also the of us 24 years later are still flying. The two of us are captains with Air lingus and the other one back to the UK where she came from. She's a captain with virgin I. So there's a few of us out there and I know a few others as well. There was an eye surgeon from Belfast joined just before me. Uh he's captain with British Airways now. So there's actually a few of us knocking about who could share our experiences. But I think I'm the only one who's actually set up a business tran to sort of share what we have learned. But uh again, you said, as you say, I left in 1999 and the main reason I left was just due to lack of training positions. Really, I was quite happy. You've been a cardiac surgeon. Uh overall, if you count medical school, 12 years of training done by that stage. Uh And as you know, yourself, cardiac surgeons tend to be quite committed individuals. It's not the sort of thing you drift into. I had quite happily stayed on. But unfortunately, it was during the S P R training system when it was betting in. Uh and there's just simply wasn't enough jobs to go around and some of us were going to fall between the stools and I was one of the unlucky ones. But lucky enough, I saw an escape route to give me a career outside of that, which I took advantage of then. Now, why did you choose flying? How the skills transferable, uh chose about pure flick. Uh The short list for the training job, the SPR post I was going for in Dublin, uh came out on the Monday. Uh I hadn't made the shortlist. Uh Obviously, they're just, there was 13 of us and there was only uh one training post coming up. Uh 13 registrars in the units that wasn't gonna be enough, enough room for all of us. And I didn't make the cut down for said leave. So that uh the interview for, uh so at that stage then, uh they worked out during the week then that I'd already been shortlisted in Massachusetts channel in Boston. Uh couldn't get into the States. I couldn't get into Australia because, you know, there's jobs available in all these places but not training posts. So they don't actually lead anywhere. Uh So by the end of that week, I had worked out that I basically didn't have a future in surgery. Uh It was probably two senior at that stage to go back and start again in another specialty. And the following Sunday earning this just by pure coincidence, had a half page ad and one of the Sunday newspapers. So I saw the ad rang up and went from there just 4.5 1000 of us supplied and I got in number 11 of 37 that year. Goodness gracious. So other skills transferable and I didn't feel learning something new because you hadn't flown before, had, you know, I uh interest in flying before that again, cardiac surgeons tend to be quite committed people. You don't give time for anything else. Uh When I go to college. I, I raised bikes as an international cyclist. Uh, when I started training a security back surgeon, I was actually on the Commonwealth games cycling panel for Northern Ireland. But then all that went to the wall as well. Once the, uh, the Irish kicked in and 1900 are weeks, weren't really compatible with an international cycling career. So, uh, when I actually started flying, I had no background, I had no hours done. I had no history of aviation. I just saw that there's a career that I think I could learn how to do. And at the interview, when I think the interview was about stage four of eight in the process, and I basically went and said I have no no background, aviation. I have no history in the aviation. But I think I can learn how to fly an airplane. Please give me a chance. And that was the whole basis of the interview. And that was, that was my selling point. And after speaking to the two captains that interviewed me a couple of years later when it was actually flying with them, they said that they realized very quickly that I would be capable of getting through the system. They said most of the interview was based trying deciding whether or not I was going to stay because they just couldn't understand the concept that someone could train for 12 years and be left in with no opportunities, no possibility. Of actually having a training job, it just doesn't make sense to them. So, so some of the mentality in aviation, so it doesn't transfer. But a lot of the skills then I ended up using, it took me about 10 years to realize how transferable they were. It was only after I trained as a captain and realized that a lot of what I've been taught as part of my command training was actually human factors type stuff and how to interact with other people and how to sort of make use of the resources around me that I assumed it was going to be, I had to memorize an awful lot of stuff about the airplane and so on. Now, obviously, there is a basic level of knowledge that you need. We do need to know quite a bit about them, but they actually prefer you not to know too much because they changed on a regular basis. So they want you to have a general for the background and then be able to go into the books quickly and find the information. And obviously that that's something I already knew from, from healthcare that you didn't always know the answers, but you had two fairly quickly try and find them and, and the ability to see, seek answers and know where to find them. Was that the key then? Well, that was part of it again in so cardiac surgery, we tend to uh be very driven people, once you've opened the chest, you're committed. Same thing once I've taken off, regardless of the weather, I'm not committed, I'm not airborne. Uh, whatever happens sometime over the next 12 hours or so, I'm going to have to land that airplane somewhere. Uh, it's a similar case. Once you've opened the chest, you're not committed to actually doing some sort of procedure. Uh, you're going to have that you can't stop halfway through. Uh It's a similar mentality. So you have to plan ahead and try and plan for scenarios. Uh That's one thing I found wasn't really sort of very formalized in healthcare uh in aviation. One of the main things that I teach when I try and transfer our skills is working this go wrong. What's Plan B uh as we already found out tonight, uh When we logged on before the interview, I was on uh safari and after about five minutes of chat and to make sure everything was working right. You started getting feedback from me. So I have the log out and log in via Chrome and Gabrielle. Very generously sent me another invite which I logged on to a different email account. So I've managed to log back online. So we always work on the basis that things are going to go wrong and we always have a Plan B ready to activate fairly quickly to try and sort of bias time. We seem to have worked here again in health care. I think uh some surgeons would have a backup plan, but I don't ever remember one being shared with me when I was in theater that I'm sure my consultant had a plan if things went wrong, but I wasn't aware of it. Not, I think, I don't think anyone else in the theater was aware of it. Whereas an aviation, we have a brief beforehand where we discussed all these things we say like if it's such and such a scenario happens, this is what we're going to do. So we're both already discussed through it so that we all know exactly what's going to happen next. I must comment now as we had that sound issue before we logged on and we were communicating, your responses sounded just like Sully landing on the Hudson. Uh I'm going over to Chrome. It'll be two or three minutes and it was so clear and so precise. It just reminded me of that episode. Does that come through from surgical training or how have you learned that as a pilot? I think I alert that as a pilot. Now after I left aviation has started, started adopting or healthcare has started adopting some aviation principles. Uh One of the big communication principles they brought on board after I left was his bar. So obviously introduced. Uh So if I'm ringing you as, as your registrar, when something's gone wrong at four o'clock in the morning, I'd introduce myself, smile and the right to start on call tonight. David situation. I'm ringing about your patient that we operated on this afternoon background. He was the guy who did the mitral valve repair and two graphs on uh he's not used to deteriorating. There's blood coming this trains. So I've tried to stop it. It's not working. My assessment is he's bleeding internally and we're not gonna be able to control it. Uh So it was reopening them and response. I would like to take him to the theater and I would like you to come in and help me out. So it's a very structured sort of response. Now that wasn't there when I was operating that human afterwards. Then aviation, we have a very, very similar setup called the Nets Brief. So if something goes wrong, we can communicate through a structured system to the cabin crew, but as well as the actual sort of structure, uh we see that we see everything in aviation is a three stage process pretender everything in the rule of three's because we can't carry more than three thoughts at once. Uh So one thing that has to be taken into account, let's say if there's a message I'm the center. So I know what I'm going to send. I've got a structure in my head. I have the message which will be the nets brief, but what often doesn't get taken into account is the receive. Er, so say if I catch fire I'm going to Chicago on Wednesday morning. If I catch fire when I'm leaving Dublin, I'm going to be calling back to the cabin crew to give them in its brief. So if my nets brief starts with right, we're on fire. This is what we're going through. This is the time available. This is the special instructions. Uh Chances are the cabin crew members only going to hear one word and that'll be fire. They're not going to actually pick up the message because again, we work in a fight or flight response. The human factors is that when you're in an emergency situation, you go into a fight or flight, you get what's known as the Amygdala hijack, which I'm sure you'll be familiar with uh Amygdala at the bottom part of your brain, uh sort of takes over. So it's part of your hindbrain. It shuts down your prefrontal cortex that you use for analyzing things. Uh start pumping out cortisone and adrenaline and get you ready to turn and run because obviously there's a tiger about the attack you. So we need to have a way of getting around that. So when I call out to the cabin crew, like my first instruction isn't the actual message. My first instruction will, will be we have a problem here. I'm going to give you an it's brief, tell me when you're ready. So that gives them time to get over the initial startle reflex, go and get a pen and paper, maybe compose themselves and then be ready and they're not ready to receive the message in the next format because the cabin crew and air traffic control and everybody are trained in the same structure. So then the actual message can come across. So nature were on fire. Intentions were going to do an emergency landing back in Dublin time available. We're gonna be landing in seven minutes. It's now quarter past eight. So we'll be landing at, uh, what is it? 22 special instructions, we're going to stop on the runway and we're gonna be surrounded by fire, fire engines and trucks remain your seats that I give you any further instructions. And then the next point now is, I don't know if the receive, er, has actually taken that on board. So we get it from communication. We use a closed loop format, but you're gonna don't ever remember in surgery either. So the next instructions now read that back to me and if they miss any parts, I repeat it and get them to read it back. And if they miss anything again, then I just say getting the number two cabinet, remember and we'll start the process again. So we're very structured in what we do that we have a structured way of communicating, but we also make sure that you've actually received the message in the format that I've given it because you might take something out of it. Different what I actually said and unless we confirm that you're not going to go off on a tangent and taking the different problems that the one that I'm dealing with, have you ever seen that in theater in your training experience now? Well, obviously I say I'm out since 99. Nice. I know it's 24 years. I don't remember ever seeing that sort of structure in theater. Uh, I don't remember plans being sort of shared with uh staff. I don't remember before we started a case sort of discussing. Well, here's what we're going to do. Uh Here's the different scenarios. Uh Here's the risks. Uh The only thing I really ever remember being sort of considered seriously was myself and the senior registrar were operating on a Jehovah's witness patient because obviously we didn't have the safety net of blood products. So we went into it a bit more detail. But beyond that, I don't ever remember having sort of plans shared with me. I don't remember communication being done in a structured format. I don't ever remember being asked for a, a redback if you like to confirm that I had received the message that the consultants may have thought he passed on. So we're looking for it from the flying perspective in the moment. But what have you incorporated as a pilot and the captain that you learned as a surgeon? Yeah. Uh well as a surgeon, we, we tend to, again, we keep going until we get a resolution regardless of the hours. Obviously, in aviation, Irish, a lot more controlled than they were back in healthcare. Uh, when I was in Dublin is a registrar in the cardiac unit there. Once a month, we would do, we did one in four on called road. So once a month that meant a 56 hour unbroken shift. Uh, so we, we tended to be able to keep going regardless of, uh like this, the situation and aviation, our hours are a lot more controlled, but obviously that's, that's great. As long as it all works out. If you're up there and your hours have expired, you still have to land the plane. So again, like, one of the things I've sort of brought in obviously is you been able to keep going until you've got a satisfactory resolution regardless of things like ours. Uh I think that will be critical. I've taken more from aviation back to health care. Then I took from health care to aviation. But as I say, I'm 24 years now, a lot of things have changed since that. I think healthcare has caught up with a lot of our stuff and there is a lot of very good work going on. People like yourself, Peter Brennan and Martin Bromley have been pushing an open door and trying to get a lot of our skills across people that can catch Paul and Stephen Shark from the human factors, professionals have done a lot of work now, just be clear, I'm not a human factors professional, but I'm a professional that relies on human factors to keep me in my passengers and crew safe. So I've taken a lot from the human factors world that I know I apply to both, both industries, even though I'm not actually qualified as a human factors professional. But I think Stephen and Ken have been very clear that that's one big thing that needs to change in the NHS. Uh Stephen was telling me apparently there are about 10 qualified professionals in HF in the NHS between 1.4 million uh staff for comparison. Uh He works for, for nuts, the National Air Traffic uh service. Uh They have 30 human factors professionals and they have a staff of about 3.5 or 4000. So healthcare is way behind from human factors professional point of view, which needs to change. But in the meantime, what I'm trying to offer is like someone who uses human factors on a daily basis that we can try and transfer what we have learned, which isn't quite as good as having human human factors professionals there. But I see it as a stopgap or personal protective equipment. So PPE for staff, why they're waiting on the cavalry to arrive? So now what would you take back? What would you advise a learning surgeon going into the theater and environment? I I like the analogy, you've opened the chest, you got to go through it and you got to close the chest. In other words, you've got to take off and now you've got a line the plane safely. And that, to me is very visceral and vivid. What would you do advised to take that message back into a theater environment? Well, I see there's a three stage process. Now, the trainees could limited sort of, uh capabilities of bringing a lot of that to do. Uh the three stages. What you see is that what needs to change in healthcare is at the minute, I think everyone accepts. There's a name, blame, shame, retrain culture, uh which hasn't been very successful. Uh People tend not to report anything that happens because if they put their hand up, it tends to get shot off and healthcare staff are intelligent people. If you're gonna get uh uh penalized for reporting an incident that nobody's noticed as human nature that you're not going to put your neck on the line. If it's not gonna be a welcome message in aviation, we have a just culture. So the idea is that if I make a mistake on Wednesday, when I'm heading off to Chicago, I can put my hand up without any fear of disciplinary actions or dismissal and report that incident. As long as first, it's not gross negligence and second is not deliberate harm. It's obvious it's not to get out of jail free card either. But if we make a genuine mistake, we put our hands up and report it. Uh that can be reported actually from our ipad system online using are on board wifi. So I can actually report an incident like mid Atlantic as is happening so that they're see if the office can already be looking into it before the flight has even landed. Uh We then take that report and look at it and the logic will be while you've been flying 24 years, you've had that incident today. Uh If it was that you weren't good enough, chances are you have made it before now. So the problem is obviously a systemic problem. So we then look for what went wrong rather than who went wrong. Whereas I think in healthcare, as you said, in your introduction, uh we tend to look at who's the last person to touch the ball and they carry the can for us. Uh That system doesn't work. I think we've seen over the last sort of uh 50 years. Even the figures have gone back. Healthcare has made very little improvement in the number of adverse events they're having. So it's obvious that talk, evidence based practice. Uh The evidence would suggest that the system as is, isn't working. And lastly then what we trained then is uh we expect staff to make mistakes, we expect them to make ours. So we train them in anger management. So the idea is that we have a structured system which is where CRM fits into it, where we expect to make mistakes. And then we try again a three stage process. We try and avoid them. If we can't avoid. If we miss that, we try and trap them. If you miss that, we try and mitigate them before they cause the death of a patient or an airplane crash. So we have all these different layers of safety nets. So we dig into the system, try and find what the problems are. We use our CRM system, which looks at the communication especially. Uh we already discussed that communication in both healthcare and the aviation uh leeds the 70% of adverse events. So if we could focus even on that, we can make a huge impact and then secondary things in Arctic leadership workload management uh threaten our management, uh team work, stuff like that. I think there's a lot of emphasis on teamwork as being human factors in healthcare. I think that's going down the wrong route really. It's a very small part of what we do. So how, how do you train that in error, identification and management and mitigation? Uh comparing your career as a pilot with the surgeon. Where's that training come from? How do you do that? Uh Well, first of all, when we report instances, they say we're a small airline, we would report up to maybe 20 times a day on things really. Yeah, but they're all very small. But he thinks, but in aviation, we found that the, again, James Reason Swiss Cheese Model, uh that was a very small hole in the slice of cheese. Uh If we just wave that through those small goals, keep accumulating. And eventually, if nobody ever deals with any of the holes, they'll all eventually line up Sunday and then you'll either crash a plane or kill a patient. So we try to identify all those small holes and repair them as we go along so that we never get to the stage of a near miss or a major incident. Can you give us an example now or what are the small things would be to try and put it in context? We'll say uh when were taxing, say I just transferred to the 3 30 as you say, it's a very big airplane. It's uh when we take off when I'm taxi night, uh I'm usually around about 220 tons weight. So that's an awful lot of momentum. Uh If I'm taxing around a tight corner, uh we try and restrict it to so less than 10 knots, which is say about 11 miles per hour, which sounds almost stationary. Uh But if I go around it faster than that, uh my nose wheel can start sliding and juddering, which can damage the tires, can damage the whole undercarriage system. So say we have assessed them in our our planes is, it's like calamity that like the Grand Prix cars have. So we can actually so record all sorts of parameters. One of them being our taxi speed. So we would notice things uh say, but if, if all of us are taxing around corners at 20 knots, uh everyone's gonna juddering the nose wheel and that's going to cause damage to the plane eventually. So even if we don't report that it'll actually show up in our, it's called the Operations Monitoring System Ups Monitoring. Uh That'll actually flag up that hold on. Like all our guys are taxing like around tight corners here at 20 knots. That's gonna damn into the airplanes so that you can. So if you don't declare it, it's there on the system anyway, some of the things are, some of the things aren't uh stuff like that, the gap, it flag up any way we can then report that back to our training department and say, listen lads, we've noticed that there's an awful lot of people disregarding the turning around the corner at 10 knots rule. Uh Can you re re emphasize that uh sort of at the next training? And can you incorporate that into your seven liter training in the next six months block? We also have a monthly newsletter that comes out reporting any incidence and given any feedback for stuff that's happening both in the airline uh in the overall group because we're part of the I G group now part of British Airways and Iberia and doing, uh and also on a global level. So things like that could be fed back on a monthly basis. Just to say lads, we have noticed that there's been an awful lot of episodes of this happening. Can you just reassess that we need you to do something different? So that's even with I just reporting things, uh any other things that might not flag up in the UPS monitoring system? They say if we, if we're working out are sort of take off performance that's done at the last minute once we get what's called the log sheet. So we have a fair idea before we leave the office, what weight we're going to be as we can have an idea how much power we need to take off on the runway. But we always do a final check when the doors are closed. They say, well, how many passengers that we actually finally end up with? We maybe get 10 passengers the last minute, which is actually nearly a ton of weight. So that would need to be factored in. So when we're doing our take off performance figures, I might accidentally type in the wrong numbers. So that is in 220 tons. I might put in 215 tons and then only notice it after I'm airborne, but maybe through sheer good luck, we got airborne safely because we're enough of a margin built in. So if I happen to notice that I would then flag that up on our reporting system that I made a mistake. This is what we did. We got away with it today in other weather conditions and other circumstances. If we lost an engine on takeoff, we might not have got away with it. So I will highlight that it would reinforce me not to make that mistake again. It would be reported back in the monthly uh training bulletin that everyone would be aware. God known someone who is de identified. So nobody knows it was me that made that mistake. It'll be reported anonymously, but it'll come back that one of our airplanes made this mistake and it'll highlight to everybody got know that could have been me. So then when you go out flying the next day, you sort of keep that in the back of your mind that yes, someone made that mistake last week. I'll make sure I don't make that mistake. So simple things like that are constantly getting reported and get worked on. So we're constantly sort of nitpicking and troubleshooting what we do. I'm fascinated because if you had five more passages on the plane and you didn't record it. Does that mean you have to do a physics calculation for philosophy of take off or, or what? Well, we do. Well, if we have five extra passengers, an average by week of six standard weights that we use because obviously passengers come in all shapes and sizes. So we have an average that we use to balance that out. So say an average passenger, we take say 85 kg allowing for your hand baggage and stuff like that. So, so the next, the next 10 passengers say is 850 kg. That's the guts of a ton. Now it was also like I might be 220 tons. There isn't a big difference between that and 221 tons. Uh If I'm on my Airbus the 20 that I've just come off, that can be the difference between 60 and 61 tons, which obviously proportionately is a much bigger jump. Normally we have enough leeway built in. Uh that, that wouldn't be a major issue. But again, that's a, that's because we have our avoid trapped mitigate system. That's part of our safety margins, which is why our results are so exceptionally good and the general scheme of things. But if I let that slip, well, there's one of my safety nets gone. If I let that slip. But chances are tomorrow, I might let something else slip the following day. I let something else slip and after a while suddenly have let all your safety net slip and then when you make that mistake, you know, you don't have a safety margin and now you're going to have an accident. So that's why even things that seem very small. We take them seriously and we, we, we report them, we try and act on them because if we see each one of those as a safety net and on the wrong day, that safety net might be the final one that you've got. So generally things they got, they are small enough issues but small issues go less and the big issues. So on a regular flight across the Atlantic, not that this sounds regular. You would say you're reporting about 20 things a time. Know that's between the entire airline. That's the entire line. Uh 50.5, 4000 or so of us. Uh There would be about 20 reports a day going to their safety office across ground, staff, cabin crew management, staff, pilots, engineers, like everyone across the board and that's across the whole fleet that's across the entire airline, across the Gold March across all fleets 20 a day. That's uh probably small, isn't it? Compared to what with you? Perhaps see in theaters? But again, they can theaters. I don't remember ever reporting anything. I don't ever remember being encouraged to report anything. Okay. And I'm reminded by a phrase that Gary Kaplan at Virginia Mason Medical Center said he welcomes reports of errors because the more you polish, the more you shine and let's see here. And that's, that's what you're doing on a daily basis. There's a guy at the minute. Now, the Belfast intensive care nurses have taken 10 courses off us. They train up the entire, uh su niece nursing team and so split in the 10 different groups to get around the mall. And I've now done, I think eight of them and every presentation has been polished according to the feedback from the group that went before. So the people that are getting, the current presentations are getting a better presentation of the people who went on the first one. But like, that's how we learn. Uh positive feedback is nice and sort of helps your ego because the negative feedback that actually improves, of course. So I, I tell them all, like at the end of the day that, you know, they send them feedback forms with them, their, their team report back to me. And I said, no, there's no snowflakes here. If there's something that you weren't happy with, if you have better ideas, if you think some of our stuff was complete rubbish, please let me know because that's how we learn, that's how we improve. Like where we constantly sort of nitpick ourselves and start criticize yourselves because as you say, that's the more you, the more you uh polish, the more you shine. And I suppose that is the key element that surgeons can learn from pilots. Is it, do you think there's a total difference in philosophy comparing the two in that regard? I think there is and given the situation that most healthcare staff are working in. There's a good reason for that philosophy. Uh We've, we work in a fairly uh protected environment. Healthcare doesn't, healthcare is working in a very complex environment. They're generally short staffed at the minute. Now. Uh There's a lot of juniors, they're new staff coming in. Uh let's say when I speak to the intensive care of years, uh there's a lot of new staff of twins since COVID. So obviously there's an experience so they need more supervision. So there's less experienced staff like on the ground trying to help out junior staff, patient's, it's minutes seem to be getting sicker because again, a lot of stuff wasn't flagged up early during COVID. Uh healthcare staff are working in a much worse environment to what I have the luxury of uh we've spoken about communication already uh in my world, everybody that we deal with is trained in communication. So if I'm speaking to engineers to ground staff, they're traffic control. We're all trained in the, the whole same communication system. Healthcare staff are talking to patients and families who are already on the back foot given that they're sick or the family members very sick. Uh They're, they're not training communication. Uh it's harder to try and get information to and from them given the circumstances that you're working in. So I think I have a lot of sympathy for healthcare staff that what we're trying to get across. It is great, but a lot of the skills are transferable. But I make very clear that there are two very different industries. I think what happened about 10 years ago is that aviation started trying to train, uh, at that stage, we basically just CRM, which again was too narrow focus anyway. But they tried to train CRM to healthcare staff as if they were pilots and cabin crew. But I've been aware we need that. They're not and they're not working on the same circumstances as us and they don't have the same luxuries and privileges as us. But I think again, all a lot of the skills we have are transferable, but we need healthcare staff to try and work with us, try and genetically engineer them in because the underlying D N A is compatible. Whereas in the past think we tried the transplant them and it wasn't a good enough tissue match. So it got rejected like a heart transplant. It's somebody says in the questions session and please do ask questions because this is a really fascinating insight that in healthcare when we raise that something's gone wrong, people get defensive and it seems to create mistrust. So how did the airline industry avoid that defensive response and trust that it was no blame. How did you get around that? Well, it took a generation. We've been doing crew resource management stuff now since 1978 came from the 1977 10 Reef disaster. Uh That's what kick started. The whole thing. Uh the following year, then there was a big conference between the American Airlines, NASA, uh some of the big aviation bodies and that's where the whole calm concept of human factors idea really started to take off. So we spent about 45 years on this already. Uh It took a good 20 or so years for it to become sort of accept it fully across the board. Uh Some, some staff never accepted it. Uh What we did there is we basically had to wait for the them to retire and move on. Uh People like myself, I'm sort of so the more senior end of the pilot party now in the group, I've only been trained in that the, the, the human factors type system. I don't know any other way of doing it. So people like myself are now feeding that through. So it hasn't been sort of like switching on a light bulb. It took us 2 20 odd years to get to the stage. We're at uh the healthcare can get on the same stage, but we need people at the top to try and buy into that concept and get them to come on board with the idea, but it, it is going to take time. But we, we also need is uh people at the top uh space, the management level to actually buy into the idea. And we talked about creating mistrust what needs to happen is that when someone reports an issue or a problem, we need to see management actually sort of walk the walk as well as talk the talk. So what needs to happen in the trust is for someone to report a major incident and for them to be treated as a hero, not as has been being victimized. We need to see them being the issue being worked through. We need to see that staff member being celebrated for having given us the opportunity of catching a big mistake. Hopefully before, if it's a near miss, hopefully before it actually caused the problem. So again, the, the way we get around mistrust is to prove that when you do speak up, you will be treated well. But again, we need management to do that. And I think there's been quite a few examples in the last 5 to 10 years that I think we're all aware of that that hasn't happened. The Bible Garba case would be one example, which I think it sets the human factors back a decade. Uh, when someone spoke up and admitted their mistakes, they ended up being charged with manslaughter and convicting of manslaughter and struck off, that's not going to do anybody any favors and it's not gonna do patient's any favors in the long run either. So how, how do we change that then? Because it, it does seem compare contrast that as you pointed out, the healthcare industry is a long way behind what lever would you pull tomorrow to actually initiate the change? You're talking about it. Martin's talking about it, Peters talking about you named a number of other people and it seems so obvious, why isn't it happening? Well, like part of the reasons that all the people I talked to, the guy, I've spoken now to eight groups of the staff in this most recent course have been given courses now for 12 years. Uh Once in the 12 years, I've been doing this, the chief executive came to talk that was in the home button hospital in London. Uh We need to, uh to get in at the top level. We need the chief executives and the C suite people to get involved in it. Uh It's been very difficult to actually get through to them. Uh They would often sort of bring me along to talk to their staff, but they don't feel that they need to be there and like they're the people who can actually make the change when an incident happens, it's up to them to again show the staff member that no, I'm not going to serve discipline you for this. I'm going to celebrate you for this that you've given us a great opportunity to try and deal with this. So we need to see senior management actually sort of shown that they will treat people well when this happens. Uh that's going to take time to get through. We need to sort of see that happening on a regular basis. And then again, as they say, healthcare staff are intelligent people, if they say that they're uh her colleagues getting victimized, uh losing jobs and things, which is what's happened. Whistleblowers in the past, even like the term whistleblower tends to be pejorative, but we don't have that term in aviation. Uh The term just doesn't exist, we need to try and change the system that people speak up and get treated well for us. But we need senior management staff to get involved. That's it's over. Well, having junior staff replying into it. But if they then reported things that I have suggested and they get their hands shot off, other colleagues around them are going to learn from that and not do it again. So that's the big thing that needs to change. We need to see people being treated well from reporting incidents. So as somebody has asked him and is often cited, the differences between a pilot and a surgeon is if the pilot gets it wrong, they go down with the plane as if a surgeon gets it wrong in cardiac surgery. We used to say we bury our mistakes. How important do you think the shared fate concept is? I think it's very important. Obviously, when I do checklist are one example, uh when we do a checklist like my checklist safer, my transatlantic flight on, on Wednesday, it's a laminated a four sheet that doesn't leave the airplane. The focus in the healthcare story seems to be, make sure that the checklist is signed and recorded in the notes. So if it all goes wrong, we can blame someone. Uh, that's totally the wrong concept in aviation. It's a laminated sheet and nobody checks that. I've done the checklist because I don't do it for the airline. I do it for me. It protects me and, uh, sort of saved my life again in, in healthcare. That's a different scenario. You don't have the shared faith concept. As you say. When we made mistakes, we closed them up, we moved them on and we started the afternoon case early. Uh That was the whole mentality there. We didn't have the same motivation, obviously try to do your best for your patients. But if it did all go wrong, you were still there after lunch time doing the next case, obviously, the healthcare that can't change. It is a different scenario. As I say, it is two different industries. But if I try to get that mentality across that, uh I obviously all healthcare staff want to do the best. Uh Nobody goes to work trying to, to make mistakes. We're trying to do a bad day's work. But if I can try and get across that, when you do make a mistake because we all do make mistakes, it's inevitable. Uh We have to accept the fact that error is inevitable. Uh That's the whole point of my book that's coming out now, uh relation June, hopefully uh say pre orders should be open around about male going well. But the whole key concept is that everybody in every walk of life, at every level makes mistakes. So we need to have a system in place that structure going to, to deal with that, which is why we talk about error management, not sort of error avoidance. We assume that we are still going to make mistakes, but we need to learn to manage them. And that's the whole idea of sort of safety nets comes in to try and sort of have backup plans for backup plans for backup plans. Now, what groups have you experienced recently? What did you learn from it? What else have I had? Yes. Can you share a whoops as a pilot? Um, well, things like, see when we're putting in figures into sort of computer systems, uh, we, we cross check them. So that's again, we talked a close look communication. Uh, we can type say weather conditions into our computer. So when we're working out the weather conditions or working out our performance figures, so before we actually go down the wrong way, we work out what we don't use full power all the time. I mean, we could use full power, but you'll eventually burn out your engines again when you're accelerating in your car tomorrow morning. You don't usually put the both of the board, you'll accelerate according to what, what you need, you're going uphill downhill or someone. So we work out too much buyers happens. Do we need to meet all our safety parameters? But without overstressing the engines, what speeds do we need to take off at? Like what speed do we take? We lift the nose off the runway. What speed do we need to do once we actually get airborne? So we work out all that according to today's weather conditions because it changes with the temperature. The wind have a headwind, the tailwind. What's the air pressure? So when we do that, we put the figures into our, we have a computer reach beside us. So I type all those figures into my computer and type in the weight that the airplane is. And then I read those out just, there's times the research I've read them out and then the copilot beside me, we go, uh, no, that's, that's not the temperature today. The temperature is something different. There's stuff like that. It will make a very small difference. But again, we work on the basis that small differences will all accumulate, become big differences. So then I can, that's why we have closed the communication I read out right here's the figures I'm going to use and I read them all out my co pilot, but we're looking at his computer which was filled in independently and check that we have agreed. We've got the same numbers. And if you don't, you don't know that's wrong. And then we looked at one of us is wrong. We need to resolve and we get the weather, the weather figures again, we're going to have a look, see which one of us has made the mistake here and then we correct them and then we start again. So things like that, it's a very small issue, but we work on the basis that small issues. If they're let slip, well, then that more small issue slip. And eventually we'll start letting big issue slip. So great, we tend to be sort of nitpick and everything that we do so that we constantly keep our safety margins. So how does, how do you balance that with a cognitive load as a pilot and a surgeon? Not only in theater outpatients, your patient in 90 you somebody calling etcetera. How does that all balance uh to keep you focused between a surgeon and the pilot? Like in one of the sections of our crew resource management is workload management. And again, communications, one of the biggest issues. So say we would have a very structured way of doing things that we tend to try to do one thing at a time. All the research shows that multitasking doesn't work. Our brain works on a single track system. If you think you're multitasking, you're not, you're actually just uh flooding quickly from one issue to another, which is a distraction which researches all shown breaks, breaks your train of thought and breaks your flow. So we had our workload structured, right, that we do things in a certain sequence. If the sequence gets interrupted, we go back and we start again again. Healthcare doesn't always have the same luxury as that. But in an emergency situation, we have a framework we default back into against what we call the company framework. Health. The same concept is applicable to healthcare as well. We have things that our staff are trained to know. When is the critical parts of the, the the procedure. We have a stereo cockpit that the cabin crew don't get in touch with us below 10,000 ft. So when we take off, they know not to get in touch till at least 10 minutes into the flight, they generally leave it maybe 20 minutes. And when we're coming in to land, you might have noticed that when you're coming in to land on a plane, you would hear the seatbelt sign being on and off two or three times. Uh as we're coming in, that's uh two stage message to the cabin crew. One that's telling them that there is 10 minutes to, until we land. So they need to start getting the cabin tidied up and get everything finalized there. But it's also to let them know that that also means we're now passing 10,000 ft. So we're going to start a cockpit. So after they hear those things, they start getting the cabin ready and they also not to contact us unless there's an emergency. So it means then we don't get our sort of focus broken when we're coming to the critical stages of flight, when we're coming into the approach and landing face, so that they know not to disturb us at that stage in operations. Uh When we get to the critical part of a cardiac operation, uh I don't ever remember anyone being told, right? So if everyone stay quiet and I don't ask any questions, you still was a study done a couple years ago, I think uh I'm not sure if it's cardiac one or not, but they actually counted the number of interruptions during the case. And it was something like 30 interruptions like people coming in the doors asking the surgeon questions. I can just ask you something about the last case. It's like constant interruptions even if it was I never checking. Sorry. Are you at a critical stage of the operation here? So that's not broken their concentration and then we need to try and work out. So what was I doing there? We get things like that. I mean, stuff like that is very transferred. Well, I did a study where we demonstrated the door opened 60 times in one hour. I did. Yeah, I, I tried to ask people when they came in. Only those who could name the patient give their age and tell us the operation were allowed into theater. In other words, they had business and theater tried to introduce that, but that wouldn't, wouldn't, didn't fly. Excuse the pun. So what is the role of simulating them? Uh What is the role of simulation? Uh You were telling us before we went on? We do this, you are accredited on a regular basis and you go into the simulator four times a year or something. Yeah, every six months we spend two days in the simulator. So it's a six hour sizing. We do an hour of a briefing beforehand, discussing what we're going to do and what we're planning to learn. Uh, we'll do four hours in the actual simulator with a 10 minute break just for quick poverty in the middle of it. And uh the last hour then I spent three debriefing. Right. Well, what went well, what went badly? What could we do differently? What did we learn? Uh, and then before the following day will work out? So what can we now focus on tomorrow? So it's, it's fed back as quickly as that, uh, look like this, the different scenarios that we're looking at? Like we'll be asked, right. So, what two things do you think that you need to focus on tomorrow and tomorrow session will then be tailored around like how I did in today's session? So it's the feedback works as quickly as that, uh, the big advantage of learning in a simulator. Is this non jeopardy? If I get something wrong, we can stop the simulator and say, right. Well, let's work out what's happening here and why you've made this mistake and go back and try it again. When I was in cardiac surgery. There was no, sir, simulation stuff. I mean, I've been following sort of a lot of interest like the simulation training you've been doing with bananas and pieces of bacon and penny pasta and stuff. I mean, that's a fabulous idea. People can learn basic skills and totally non jeopardy scenario. And I find you in the basic hand eye coordination and things on pieces of pasta or on banana skins or, and things like that. But I think that's in credible idea. I mean, and it's so simple. We don't need regard simulators costs to go for $20 million each. Aviation things are all pricing dollars uh to avoid any uh exchange rate. Fluctuations are simulators are about $20 million each. The airplane on planes, $250 million. Uh There's a lot of money involved in that, but a lot of stuff can be done, uh even just sitting in a room. So, uh you say briefings, that's like a simulation if you like. So before we take off as we're sitting in the cockpit, I do, if we catch fire, this is what we're going to do. Uh So it's very essence, that's a simulation. We're going to simulate that when we catch fire, this is the steps in the process we're going to do. So we're up to speed on it. So if it does happen, it's only 10 minutes since we've discussed it not six months ago. So it'll be fresh in our heads. Simple things like that. But again, aviation healthcare has caught up a lot in a simulation in the last few years. Uh simulations come on in leaps and bounds. Anaesthetics, particularly think has made huge progress uh in simulation and it's great to see. But I think the next step is seeing people actually trained and then re accredited on us. So like I get re accredited twice a year in the simulator, I also get re accredited in the airplane where uh check captain was, sit in the jump seat in the cockpit and supervised me doing a flight so that we actually get seen a once a year for the live patient scenario if you like and then twice a two days, twice a year in the simulator. Uh We also have a ground school feeding. Uh what's the cabin crew for safety emergency procedures? So that's a four days, 5 to 6 days. Uh We have a ground school day that we do online that seven days, we have a medical that we have to do once a year to get signed off on as well. So that's eight checks a year. Basically, we have to pass uh obviously that's so formalize checks and that's built in to your training job plan and what is required and totally accepted by your industry as necessary. Yeah, that's just, that's why our year is structured all eight weather pilot. We all get checked in the same way every stage of the year and you are coming out with some sums and how much this costs for an individual or the system to do this every year. Yeah. Well, the simulator self placement, how much power in the simulator? Uh the simulator to rent is generally think about 500 lbs an hour. So if we're in there for four hours, that's by 2000 quid. Uh There's a captain and a copilot in there and then a training cap Norco pile as well. She have three pilots in there. We aren't earning any money for the company that day because they're not flying the airplanes. Uh And then multiply that by the number of times per year, but all that it is, it can be expensive but crashing airplanes an awful lot more expensive. So we see it as an investment rather than the cost and the company pays for this necessary training and simulation and you all participate in doing it. What is really reassuring now that we did ask the audience beforehand, would you be willing to undergo regular simulated assessment and training? And the audience all said yes, 4.5 out of five, which is really really heartening and I think bodes well for the future. So, yeah, I think it's been accepted and like it has been accepted in healthcare, I think we just need to get staff, more opportunities on it. And as somebody who's had a foot in both camps and is a very successful captain, as we come to land this plane this evening, what would be your departing comments to the audience before we land and go below 10,000 ft? Well, think that when I give him my talks, I generally boiled the entire talk, whether it's a 10 minute talk or six hour talk. I boil it down to two or three slides. Uh The most important slides and the real focus of my book when it comes out is that errors. Nothing to be ashamed of. Uh We need to get rid of the name, blame shame, retrain. Uh The second thing, the second slide I show is working this go wrong. So assume that errors are going to happen or things are going to go wrong might not leave necessarily be an error due to a person. It's an area that something went wrong in the engine. It's no, no individual's fault. It's a systemic fault but be ready to, to deal with it. So, working, working this go wrong and what's Plan B uh when we were setting up tonight before they started, we were having problems with my assigned and the feedback. So plan B is we moved on to a different, different operating system and a different email address and logged on and that's resolved it. But we had to have a Plan B. And the third thing I, I then focus on is that when we do make a change, I think this is one big thing that needs to change in health care is what's in it for me. So I find that I'm talking to staff that when something went wrong. Uh And they reported generally, the solution is we write a procedure or process which adds an extra layer of work to the staff member. So it becomes your problem. So you reported, but it's up to you basically to resolve this and deal with uh things increase the workload of staff here already, totally overworked anyway. Uh It's not gonna survive long term. So the third thing is what's in it for me, we need to restructure systems to make things easier for staff and try and help them. And that's the whole basis of human factors. And that's why I think we need more human factors professionals in the health service like can catch polar Steve shark. I entirely agree. And I think we need to focus on removing the frustrations of everyday work and enabling the expert to deliver what they know best. Now you work. I think at one point like the point is that one of the talks have been given recently, uh basically things like I t, I know that's been an ongoing issue in the NHS 80 cyst, uh, talk I was given in the hospital recently. Uh, I wasn't able to connect my Macbook because they block Apple. Uh, I couldn't log onto their server to load on my presentation because they wouldn't accept my memory stick. I couldn't email it to them because, uh, they, their server blocked incoming emails from anybody who didn't recognize. So I ended up giving my presentation remotely from 6 ft away. I actually got the staff there. They sent, they sent me uh Microsoft teams invitation which I accepted from my laptop, logged onto their wifi system which was about hit and miss as well. And I presented my presentation to the room remotely while standing in the room. Thanks a system. I, I think, I think it's remarkable because I noted in the photograph that you sent me, you and you've already said you've got a laptop in front of you and we have communicated by email with you transatlantic. And it reminds me of the uh business module I did for my M B A and I called it Pie in the Sky patient, integrated, efficient I T system customized for you. So it's great. Sign me up now. I'm extremely grateful for you joining us this evening and stimulating conversation and fabulous insight. We have a lot to learn in the airline industry and I think as training and learning surgeons, we have to accept that we are fallible. We open to errors and my plea to you is be honest, be open and learn. And now thank you very much indeed for joining us. Thanks David. My pleasure, Gabrielle. Thank you too for joining us this evening. And I'll let you both into a little feedback that during our talk. Now, my screen went blank and I couldn't see anything whatsoever.