Human factors in aviation errors – The Dirty Dozen


Following a spate of aviation accidents in the 1980’s and 1990’s, Transport Canada and the aviation industry came up with the aviation ‘Dirty Dozen’ – human factors in aviation maintenance that commonly lead to errors.

Consider these in the context of your prehospital or emergency service:



(thanks to Tim Leeuwenburg at for this one!)

Analysing communication errors in an air medical transport service

The importance of effective communication

The importance of effective communication

A recent study published in the May-June 2013 edition of Air Medical Journal analyzed a randomly selected group of quality assurance reports looking for communication errors. Quality assurance reports examined had been submitted in circumstances of issues, adverse events, or simply high risk activities (for example patient requiring intubation, or scene times exceeding 20 minutes)

Of 278 reports analysed, 58 (21%) were found to involve communication errors. Communication errors were categorised according to Clark’s Communication Level Hierarchy:

Level 1: CHANNEL – establishing a means of communication between people – e.g verbal communication, digital communication

Level 2: SIGNAL – the transmitted data, for example the sound in a verbal communication or the text in a digital communication

Level 3: INTENTION – the semantic meaning derived from the content within the data

Level 4: CONVERSATION – the joint activitiy that is understood between people communication (e.g. shared mental model)

Of 65 communication errors found (from 58 reports), less than a third had been identified by staff as communication errors. Communication errors occurred most commonly at level 1 (42/64) followed by level 4 (21/64). Level 2 and 3 failures were rare.

The most common communication issue was failure to communicate change in plan or status.

The authors concluded that current quality and safety reporting systems may lack the sensitivity to identify communication errors, and that improvements to the ontology of quality and safety reporting systems, user interfaces, and staff education on reporting of communication errors could enhance the safety of air medical transport services.

Read the full article HERE (secure area limited to ADHB staff only – ADHB has subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)

With thanks to Russell Clarke

Emergency Medicine = Combat Aviation!

There is currently a huge amount of interest in lessons that medicine can learn from aviation, including concepts like CRM and the use of checklists. Efforts are being made to select and integrate these concepts into a form specific to emergency medicine – Andy Buck’s blog Resus Room Management is a great example of this, and is well worth a read.

Joe-NovakJoe Novak, an emergency physician who is a former F15 pilot (!) feels that due to its chaotic nature emergency medicine is analogous to combat aviation! These concepts are discussed in a lecture presented on Scott Weingart’s

Click HERE for the show notes and podcast



In combat aviation:

  1. Aviate
  2. Navigate
  3. Communicate

In EM & Critical Care:

  1. Resuscitate
  2. Differentiate
  3. Communicate