Human Factors and Safety

27 Nov 2012

I am by any measure a  frequent flyer averaging at least 2 flights per week which includes Trans –Tasman and interstate, a necessary part of the job. Delays are part and parcel of the experience, it happens from time to time and given the logistics involved in getting an aircraft off the ground it seems tolerable (perhaps only if you are not making a connecting flight at the other end).

On Monday of this week I had, what was for me a unique experience, it has stayed with me and I am still processing the details. I had boarded my 7.30 a.m. flight from Auckland to Sydney (I won’t name the airline, the reason why will become apparent) the aircraft doors had closed and the flight awaited take-off, the cabin crew preparing in the usual way. The first officer then made an announcement; the flight would be delayed for at least 45 minutes, nothing too unusual in that. It was what he announced as the reason for the delay that has had me reflecting since …. “Ladies and Gentlemen apologies for the delay …….on external inspection of the aircraft a bird’s nest has been sighted in the wing” (my emphasis). He then joyfully added that engineers had been called and would remove the sticks and straw. They duly did, I saw them first hand as they clambered onto the wing to work their magic, we departed some fifty minutes later, sans nest and I am happy to report without incident. As you might imagine I took a more than usual interest in watching the wing flaps in action on take-off, occasionally during the three hour flight and again on landing.

Over the past two days I have been sifting my way through a series of questions about the event and what can be referred to as a near miss; has the plane been parked in a hangar for a prolonged period? (understandable in the case of maintenance and access for critters of all varieties). Is there a species of bird, among the approximate 10,000 world-wide, that is a rapid nest builder? (I am thinking overnight here) and or one that possess a keenly developed sense of irony? (small feathered bird nesting in the wing of large metal bird ). Then there are the more mundane questions of; how long it has the nest been there? It’s origins, international or domestic? The list goes on and you will no doubt have your own line of enquiry.

While I appreciate the fact that the offending nest was sighted on the final visual check pre take-off and subsequently dealt with, I can’t quite scale the initial hurdles of enquiry vis how it got there in the first instance? and more importantly how it managed to go undetected through a series of detailed mechanical checks? from hangar to departure gate, city to city or at worst country to country.

From a health sector perspective we have looked to the airline industry, particularly to their use of  the science of human factors, for insights into process improvement and how to reduce risk and patient harm in highly technical settings such as operating theatres. It has proven a useful exercise and the positive results are well recorded in the formal and ‘gray’ literature. Taking a health perspective the take home message from the experience for me is reinforcement of the importance of taking nothing for granted when part of any complex process where safety is a priority, that final check by a competent, experienced and alert member of the team is critical.  On the lighter side I am relieved to have travelled safely and to avoiding a screaming tabloid headline ‘ Birds nest puts two hundred passengers in the soup’.