In naval aviation, there are only two permissible places for a maintenance tool: In a technician’s hand, or in his tool box. There is a tool inventory before each job, and a tool inventory afterwards. If a tool is found missing, the entire squadron is grounded until the tool is found. Because it’s got to be somewhere. And the default assumption is that if it’s not in the tech’s hand or in his tool box, it’ll be in the spot where it can do the maximum damage. Because we all kneel at Murphy’s altar.
Look who’s giving lessons to who:
Surgeons hoping to improve patient safety traded ideas yesterday with military pilots – trained professionals who also know a little about performing when the stakes are high.
In a hangar at BWI Marshall Airport, Navy pilots described efforts they take to ensure that stray objects don’t get caught in their engines, that their every mistake is recorded and reviewed, and that they practice new tasks over and over on simulators before they attempt them in flight.
The parallels between surgery and aviation are gaining traction in an era in which doctors are under pressure to reduce medical mistakes that account for an estimated 100,000 deaths a year in the United States.
A number like that makes the Marines look good…
Lex,
Let me tell you about that tool thing. One of the most disconcerning times, as in rather fearful, I ever had was shortly before my last deployment.
My crew was tasked for a 12 hour aswex pgg of Newfoundland with a US boar. While were were preflighting, the mechs were finishing some unknown tasks on ^3 engine. They vuttoned up the acess panels, packed up their tools, pulled away the engine stands and we went about our business.
Avout 2 hours after takeoff, just as we were well and truly out over the cold dark water, we get a message from Maintenance Control that one of their screwdrivers is missing. Iy was missing from the toolbox that was used on our aircraft.
To say it was a rather long flight home is an understatement. Their are all sorts of places for a screwdriver to get caisght up on inside a P-3 engine’s nacelle, and evem ,ore places where it can do very bad things.
Suffice to say, we got back just fine, and located the tool. It wasn’t on our aircraft, but had been “left on the engine stanf by the mecjs who were in a hurry to close up shop and get onto something else.
Those few extra seconds they should have spent making certain everything wads where it was supposed to be cost many thousands of dollars in a cancelled exercise and much wear and tear on the morale of my crew.
It was undrstood that the sunsequent Captaon’s Mast was a lively affair.
What’s next OR resource management?
Tool control in the Army is an entirely fiscal thing (the aviation side excepted). God knows I would hate to pay 7.86 for a 3/4″ socket.
Oh, that Hizzoner Murtha had pursued the path of medicine as that would have given a real target to pursue: 100,000 medical mistakes per year.
My, that would have kept him busy… and he wouldn’t owe the Haditha Marines an apology… long overdue!
Wow!
Tool control in the surface navy consisted of me handing anybody who showed up in my office with a 1250 to buy a tool, a bucket and say, “head for the bilge!”
OTOH, as a CHENG in San Diego I came up with an alternative strategy and that was to send them to NOLF IB DRMO with a letter authorizing them to take back into naval service anything they wanted including the 99% complete tool boxes that aviation squadrons used to be in the habit of discarding simply because it no longer contained the 9mm wrench.
Those were some cheap tools.
Growing up reading Astounding Science Fiction
magazine I was always impressed by it’s editor’s
constant pushing of the absolute necessity of
appending Finagle’s Corollary(“….and at the worst possible moment.”) to Murphy’s Law. My time in the USAF did nothing to disabuse me of the absolute truth of both. Right up there with em’ is :”If it can possibly be installed backwards,
eventually it will be.” (This is especially true of
electrical harnesses, leads, etc.)
Which also leads to a whole bunch of others, as a Marine Major so insightfully cataloged in his book about GULF I “F/A-18 Over Kuwait.” A few jems: “When your low on gas the Tanker always leaves station right on time, but is always late coming on station.” “When low on gas the Tanker is always headed away on the outbound leg of the orbit.” “The tanker always manages to find the most and/or only turbulent patch in a sea of clear air to set up his track.” (of course these were USAF Tankers, but then I’m in total agreement, AF type tho I am)I’ve paraphrased a bit, forgotten the others, but the book was a good read. I’m surprised, considering his non-PC comments about females in the services and in combat (with which I totally agree) that he managed to publish while on active duty. I’ve often wondered if he ever got promoted after the book was published or if it was a career ender.
Curtis, you reminded me of something: I was working in the engine room of a Fig, and dropped something down below the deckplates into that evil bilge in the MER. I pulled up the plate with the biggest opening, and fewest pipes, and went after it. While down there, I found a very nice 12″ crescent wrench and an operating manual (the plastic ones that usually hang on vital machinery). Being the good yardbird that I am, I grabbed all of it on the way out. When I stick my head out of the deckplates, there’s a chief looking at me. I handed him the manual, and he asked me about the wrench. I told him hell no, that’s my wrench now, you’re guys were too lazy to go after it, and I wasn’t when I went after my tools. Chief backed down, and I think the point was made to him
Byron,
When I started out as an honest 600 pound snipe the bilges on that ship were painted white and I swear you could eat out of them safely if that was your thing. When I turned to the dark side, Diesel CHENG it was another story altogether and the bilges were dark, dirty and deep in spite of my very best efforts. I think I’ve mentioned before in Lex’s fine blog how my snipes once managed to break a pier in half with nothing more than a donut. When running a Packard plant one needed a donut 24/7, just not one that has drifted under the pier at low tide and found new life as a pier wrecker on a weekend.
Had you dived into the ME room bilges you would have come back up with 23 tools and the arc of the covenant since it was probably hiding somewhere down there alongside the tools and EOSS.
100,00o a year basically die due to a Doctors mistake(s)- big number. That’s a helluva lot more than all the homicides and traffic deaths put together in any year…Chew on that.
b2
b2,
We also kill more people on our highways (some 25,000/annum) than we lose to violent crime.
And Tim, the majority of those road deaths are directly the fault of a LEGAL drug: alcohol.
A curious juxtaposition in this story – no offense intended for those who are stick/throttle interfaces professionally … but the tool control issue belongs to the trades – not to the pilots. Why are the MDs chatting with pilots about a task that is the daily responsibility of a wrench bender?
In the OR, the scrub nurse and others do the counts for the MDs. The MDS are responsible for the procedure but they don’t count needles. Seems we should have the OR staff talking to some bosuns and CPOs to learn the ins and outs of tool control
No offense to any, including our marvelous host, I’m just sayin …
VZ, when I was about five years old a fully-loaded KC-135 crashed in our environs, having attempted a take-off at Offutt AFB. During the investigation, it was found that some time earlier, during one of those periodic 30-minute drills SAC was subject to, a motor controlling the trim tabs way up there on the aft stabs had burned out and was replaced. But once on the ground the mechanic realized he had reversed the leads on the servo. Time was too short to go up and fix it, so he informed the crew, who happily flew the plane away by toggling the trim cap (whatever it is on the KC-135 yoke) the opposite direction. In those days SAC kept the crew paired with the plane, the wiring was never fixed, and no one griped it. Then one day a new crew got assigned the plane, and the pilot no doubt desperately drove the trim opposite the direction he wanted, and the plane into the ground.
And when my father was a young AF E3 or thereabouts, he loaned someone a wrench he had checked out, then went off on pass. While returning from pass, his bus went off the road and he broke his arm. While in the hospital, accident investigators wondering why his wrench was found in a newly wrecked aircraft found him. 24 hours later, after literally being interrogated on a bench with a light beamed in his eyes, sleepless and in pain, he told the investigators to either arrest him or get out of his way. Only thing that saved his young hide was the honesty of the borrower, who confessed his misdeed. A very, very dear lesson learned.
OldSchool ~ that was my thought to. MacGyver used to be responsible for the tools as a flight engineer until he went to flight school. Now they won’t let him touch them.
Heh.
OS- But it sounds so much sexier to the general populace to say “pilots” and “doctors.” Also, it’s a little less cumbersome than writing “operating room nurses” and “aviation machinist mates.”
+1 for the idea, tho
Re: oldschools point, and after further cogitation, I think they really are doing something along the lines of CRM/ORM training for the docs. Probably something along the lines of the brief/preflight thing as well. My very limited experience with surgery showed they just didn’t do that very much. It was a quick look at the charts and x-rays, and “hand me the knife”.
Why are the MDs chatting with pilots about a task that is the daily responsibility of a wrench bender?
No kidding. The pilots have more in common with the patients than with the doctors.
Yes, but the principle of zero permissible errors is the same.
Aviation is cautious, because pilots know they are always the first at the mishap site. Medicine is sloppy…not just in tool control, but in CRM and fatigue management.
Because you don’t hear about bad doctors being consumed in a pyre of JP-5.
As a bit of an aside, wasn’t there a post here not long back that talked about medical personnel starting to use checklists to ensure procedures were properly done, and having got that from the B-17 story?
Bruce, here’s the article from “The New Yorker” magazine. I downloaded it and saved it just to remind me to not forget to use *some* sort of checklist, so’s not to forget some simple things, like GUMPS.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande
Hope it links ok.
Jim,
The link works for me with Firefox 3.o. I found it from Jerry Pournelle’s web site, where he mentioned it was required reading for human factors folks. I just wasn’t sure if it was brought up here as well.
Thanks for the link.
Fishing for a reply from a Marine airwinger? Every tool, every time. I saw ejection seats pulled looking for tools, or screws. Because it wasn’t just tools, it was every bolt, washer, nut, fastener, every bit of wire snipped, or wire wrapping. Once saw an aircraft grounded because a Marine reported a missing button on his coveralls. Every inspection, every time, because the truest thing is Murphy lurks.
On the flip side of that, I once was on the flightline when a ordnanceman pickled off a full centerline tank. Murphy was there too, and it’s an interesting story.
Semper Fi
TINS, 1968, VA-42, NAS Oceana, the squadron had an open house. Mom climbed up the stand and stuck her head inside the cockpit. And the gum fell out of her mouth.
They had to pull the seat to find it. Dad was pretty mortified that the wrenchbenders had to work extra because of the skippers wife.
Mike M.
Because you don’t hear about bad doctors being consumed in a pyre of JP-5.
But that’s not such a bad idea. You could even use some lawyers as kindling…
ASM826, when doing telco or network circuits, or much of anything else for that matter, I can always tell the folks with prior military service.
They’re the ones who bite the wires they’re about to cut (so the short bits don’t go flying about), and put tools back in their holders or a pocket immediately upon finishing with it.
Two habits I look for when hiring people. Shows attention to detail and cleanliness.
– Max
Hmmm, interesting article. As a surgeon I can attest that great care is taken to prevent “tools” from getting lost. As mentioned above, it is not the surgeon who counts tools (sponges, needles, instruments) but the scrub techs and the circulating nurses who do “counts” and verify them constantly throughout the case. But, as any regular reader of Lex’s would appreciate, while excrement may flow downhill, responsibility flows uphill and it is ultimately the surgeon’s error if something gets left behind.
I find the figure of 100,00 deaths a year from medical mistakes misleading within the context of this article. Very few of those deaths could actually be attributed to retained surgical instruments after surgery. In fact, the great majority of them are due to things such as hospital acquired infections which are much more difficult problem to solve than putting a tool back in a tool box.
Hospital acquired infections are the result of bacteria capitalizing on our attempts to cure. Common examples include the use of ventilators and bladder catheters, which bacteria just love to crawl along and subsequently cause pneumonia and urinary tract infections. The war against bacteria is probably the most formidable in the history of mankind. With the advent of antibiotics, we save millions of lives a year and kill an innumerable number of bacteria. However, the wounded have the frustrating ability to learn from the battles and develop immunity to our weapons.
This being said, for a long time systems management in medicine was lacking and only recently has truly taken hold as we aim to perfect an imperfect science. The intangibles in medicine make this a very difficult task. In fact, one interesting technology that is being developed is the use of RFID tags to prevent lost surgical instruments. One could place a tag in each sponge or instrument and simply wave an RFID reader over the patient at the end of the case to make sure nothing was left behind. Although even this has hit some road blocks, as a recent study showed the electromagnetic forces of the RFIDs can interfere with life supporting electronic equipment to a dangerous level, like turning off ventilator equipment.
This makes me think of an old joke:
Mechanic: Doctor, I don’t understand what’s so hard about what you do?
Heart Surgeon: What makes you say that?
Mechanic: Well, I do everything you do. I replace valves, fix pumps, repair pipes.
Heart Surgeon: The difference, is that I do it with the engine running.
Ortho – thanks for the professional insights.
RFID tags are passive – they have no significant energy output until interrogated. Perhaps the study that found RFID shuts off ventilators was using the transmitter/interrogators? I am a professional EE and deal with these issues all the time. Casual evidence is not sufficient in this business – but it is sufficient in the legal field, so we have a serious problem. If we can’t reproduce the failure, then we can’t diagnose and correct the flaw – if it exists in the first place. Those are maddeningly difficult challenges.
If the interrogator is the problem then you certainly don’t want it pulsing in the OR. If something else is really the problem then we need to identify the root cause.
… another old med joke:
Why do doctors hide behinds such long and fancy names: neurosurgeon for a brain doc, cardiothoracic surgeon for a heart/chest doc, opthomalogist … and so forth?
Because…..
If they didn’t have fancy names we would have no proctologists.
Have you heard of the ob/gyn who enjoyed restoring automobiles? He took a mechanics course at a local community college. He scored 150 on the final (take apart and reassemble an engine), so he called the instructor. “Well, your disassembly of the engine was masterful. Organized all the parts, no wasted motions … Your reassembly of the engine was also a study in the craft. We added fuel and it fired it up on the first crank. Masterful work.
“We had to award you a 50 point bonus for doing all your work through the tailpipe.”
Improper tool control = FOD.
FOD= Death or serious injury .
That is why the doctors are learning tool control from Aviators. Every one in Naval Aviation are taught early on about tool control and FOD. To break either one of those commandments is just bad boogie.
Been there done that personally with tool control. First time out of the gates from training command into the fleet. Was working on a transmitter to an F-18 radar set. Had a retaining ball bearing from a speed handle disappear down inside a waveguide. Didn’t even know it had happen until the part had been wrapped up and sent out the door back to the supply channels. I was doing the post maintenance tool inspection with my CDI in accordance with the Naval Aviation Maintenance Program tool control program (aka then as OPNAV4790.2H Vol 5 Chapter 10). Broken tool with out all the parts became a missing tool. Luckily we had been keeping a log at the work bench that I was at which listed all the parts and serial numbers that people were working on. So it was a matter of hunting high and low through out the ship for the transmitter. Found it just as some AT’s from VFA-87 were sticking it in to a plane. Pulled it back tore it apart and found the little ball bearing in the waveguide. Total man hours wasted was something close to and additional 48 on top of the original 15 to run up on the original discrepancy. Money wasted was something in the order of 90K. The money wasted was figured from the fact that the part had to be re-worked, the wave guide which I lost the ball bearing into had to be replaced it was something like 8K and while doing the re-work I proceed to break other components which just seem to add on to my grief. Needless to say it wasn’t my best day.
Another tool control story go like this. While on a surge deployment ashore to wonderful Iwakuni Japan. We had a new NFO she has just left the Rag and flown out to marry up with us at Iwaknui. While out flying one day they flipped inverted and she proceed to dump about five dollars worth of change and Yen out of her pockets and also lost an additional survival knife that she had in her leg pocket. All told that when she landed in stead of telling the troubleshooter and the flight line chief what had happened she mentioned it in passing while out the door from maintenance control. Meanwhile this same jet was taxing out with another crew for another flight. Had to call it back from its hold short point. The Skipper and the MO were so pissed off at her she was down in my shop learning how to check out tools and was given a cranial to go and learn how to pull out floor board in an EA-6B Prowler. So instead of getting off to enjoy a nice summer day in Japan. Yours truly was there till about sunset CDIing her as she pulled out and reinstalled floorboards and found every last dime, nickle, penny, yen, and her additional survival knife.
I have also seen people go to NJP in other squadrons for not maintain proper tool control. So think about that doctors can usually see their medical malpractice insurance go up for leaving an instrument behind. Meanwhile if an enlisted maintainer looses a tool they loose rank, half a months pay times two, and some special programs are out of the door for them because you can’t have had an NJP in the last 3 years.
Oldschool,
The study involved both active and passive RFIDs. Here is a link:
http://jama.ama-assn.org/cgi/content/short/299/24/2884
Those are some good classic jokes too.
Southern Air Pirate-
Regarding your statement: “So think about that doctors can usually see their medical malpractice insurance go up for leaving an instrument behind. Meanwhile if an enlisted maintainer looses a tool they loose rank, half a months pay times two, and some special programs are out of the door for them because you can’t have had an NJP in the last 3 years.”
If only it were that simple for doctors. While we certainly have insanely high malpractice premiums, mistakes lead to lawsuits which can cost hundreds of thousands in legal and settlement fees. It’s not unheard of for doctors to risk loosing all of their assets as a result of a mistake. While my heart goes out to someone loosing rank, monthly pay, and privileges, I cannot equate this to someone loosing $100′s of thousands of dollars, loosing their licenses, and being out of a career that they literally devoted 15+ years of training to. Thankfully, these events are becoming more unusual with the types of tort reform that many states are enacting which put limits on non-economic damages. Ultimately I think the solution would be a loser pays scenario where the plantiff must reimburse the defendent for legal fees if they lose the case. This would prevent the common practice of fishing for dollars by bringing ridiculous charges knowing that it’s cheaper to settle than fight.
This being said, mistakes do happen and sometimes are the result of gross negligence, in those circumstances the patient deserves significant restitution.
Orthopod, what you fail to see is that this maintainer is going to face a severe financial penalty, all the more worse if he has a family. I understand your position, and to a point, agree with you. The real problem is the tort system, and the manner in which too many lawyers use it to line their pockets. The bottom line, though, is that if surgeons did not make mistakes, people would not suffer physical harm or even death at the hands of someone who made a mistake. The object here is to try and aborb some lessons and practices to reduce the probablity of a mistake to an extreme minimum.
And for what it’s worth, I know Southern. He’s an outstanding sailor, and should have been an officer years ago (you should have listened to us at dinner 6 years ago, Chuch!). I’m proud to call this sailor my friend.
Courtesy of Orthopod:
“Ultimately I think the solution would be a loser pays scenario where the plantiff must reimburse the defendent for legal fees if they lose the case. ”
a.k.a. “Loser Pays”, lots of interesting discussions around on this. See also Rule 11.
Is it time to throw out the sea-anchor yet?