Safety and Justice/Did I do that

Safety and Justice/Did I do that

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Implants infection


An orthopaedic surgeon was operating on a patient and just before a new implant was to be placed, it inadvertently dropped on the floor. The surgeon disinfected the implant by bathing it in iodine twice. The implant was then placed. Later, the implant caused considerable infections in the patient which led to significant damage.

There is no clear and specified procedure for dropped implants. Later it appeared that other doctors would have chosen to have the implant sterilized, however this would have meant that the operation would have to be postponed. The choice for disinfecting the implant was understandable. Nonetheless the surgeon himself was ashamed about the infection and felt embarrassed by it, hence he did not inform the patient that the infection may have been due to inadequate disinfection.

Monitoring a CTG

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An obstetrician in training was the highest medical doctor during a baby delivery. During the labour of the mother, this trainee monitored the CTG to assess the condition of the unborn. A CTG is notoriously difficult to interpret. She had the impression that the baby was doing okay. As it turned out, it was not and the baby died.

Analysis of the CTG lead to the belief that it showed clear signals about the deterioration of the baby’s condition that would have warranted a direct surgical intervention by the responsible obstetrician. The opinion of the head obstetrician was that the trainee should have called him. The hospital blamed the trainee for not being able to read the CTG correctly. The trainee made a mistake, or even a judgement error because of insufficient training.

One could consider the behaviour of the head obstetrician as well as the hospital quite a lower level (e.g. level 7).

Separation minimum

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The controller misjudged the situation which led to a separation minimum infringement. The radar systems issued a warning to the controller to alert him of the impeding conflict. The controller can then correct the situation.

Auto-throttle connection

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The aircraft was on final approach. The left radio altimeter was defect and the crew was aware of this. They had decided that the approach would be flown on the right autopilot, probably assuming this would isolate the aircraft from the faulty left radio-altimeter. The crew did not understand that the auto-throttle system is always connected to the left radio altimeter, even when the right auto-flight system is selected.

As such, the aircraft was tracking the ILS nicely, however the auto-throttle had closed the throttles to idle ('RETARD FLARE'). The crew may have noticed this, however because the aircraft was vectored quite close to the runway, the aircraft initially had been above the glide slope and had to lose speed and altitude at the same time, requiring much less thrust. The closed throttles did probably not present an unusual state to the pilots. However, the aircraft continued to lose speed and finally stalled at about 500 ft and could not be recovered.

Forgetting a clearance

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The controller gave a crossing clearance to a tow truck, forgetting he had also cleared an aircraft to land. The work of an air traffic controller is very much dependent on the mental gymnastics of his or her brain. Although forgetting a clearance might seem elementary, the consequences can be devastating! This incident could have ended dramatically, were it not for the fact that the pilot of the approaching aircraft saw the tow crossing the runway and performed a missed approach, or go-around. Another safety barrier in the aviation chain worked as planned.

This is your captain speaking

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The captain pressed the radio switch for the ATC instead of the cabin address system. The Air Traffic Controller was hearing the captain making a fairly standard speech to the passengers. After the announcement, the controller simply said: 'you are still on my frequency, sir". The captain did not respond. Probably he was wondering what he had done, realized it, corrected his error by pressing the right switch this time, and made his address to the passengers again.

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