How clear communication is critical in preventing human errors

Introduction

On March 27, 1977, the aviation world witnessed its deadliest disaster on the fog-shrouded runway of Tenerife North Airport. The catastrophic collision between two Boeing 747s claimed 583 lives and left an indelible mark on the history of aviation safety. While the Tenerife disaster is firmly rooted in the context of aviation, the lessons it imparts transcend industry boundaries, offering critical insights into the management of human error—a concept significantly relevant to the pharmaceutical industry.

Human error, often a confluence of miscommunication, stress, and procedural deviations, emerges as a pivotal factor in both the Tenerife tragedy and the complex operations of pharmaceuticals. This blog aims to delve into the Tenerife disaster not just as a recounting of a tragic event but as a lens through which we can examine and understand the implications of human error in the pharmaceutical sector. From the miscommunications on the runway to the critical decisions made under pressure, the parallels between these seemingly disparate fields underscore a universal truth: managing human error is not just about preventing mistakes, but about creating systems and cultures that prioritize safety and efficacy at every turn.

As we dissect the events that led to the Tenerife disaster, we will explore the multifaceted nature of human error, drawing lessons that are as applicable in the high-stakes world of pharmaceuticals as they were on that fateful day on Tenerife. Through this analysis, we aim to illuminate the pathways through which the pharmaceutical industry can navigate the complexities of human error, enhancing both safety and outcomes in a field where the stakes are measured in human lives.

Background Analysis

The Tenerife disaster, occurring on a seemingly ordinary day, turned tragic due to a series of unfortunate events and conditions that created a perfect storm for human error. The disaster unfolded at Los Rodeos Airport (now Tenerife North Airport), a facility not accustomed to handling the volume of traffic it saw on that fateful day. This sudden surge in air traffic was due to a bomb threat at Gran Canaria Airport, forcing several flights, including the two ill-fated Boeing 747s, to divert to Tenerife.

Environmental Conditions

The weather played a critical role in the events that led to the collision. Fog significantly reduced visibility on the runway and taxiways, making it difficult for the pilots and the control tower to maintain visual contact. This lack of visibility was a crucial factor, as it forced reliance on verbal communication and assumptions rather than visual confirmation of the aircraft's positions.

Operational Stress

The airport's unexpected influx of diverted flights created a congested and stressful environment for both air traffic controllers and flight crews. The pressure to clear the backlog of flights and the urgency felt by crews to resume their schedules added to the tense atmosphere. This operational stress, coupled with the airport's limited capacity to handle such a situation, set the stage for decision-making under pressure—a scenario ripe for human error.

Communication Challenges

Communication between the air traffic control tower and the aircraft was hampered not only by the environmental conditions but also by language barriers and the use of non-standard phraseology. The ambiguity in communications, a direct result of these challenges, played a pivotal role in the misunderstanding that ultimately led to the disaster.

Infrastructure Limitations

Los Rodeos Airport's infrastructure limitations also contributed to the tragedy. The airport lacked ground radar, which would have allowed air traffic controllers to monitor the positions of the aircraft on the ground more effectively. Additionally, the taxiways and runway layout required aircraft to back-taxi on the single runway, further complicating the operational scenario and increasing the risk of confusion.

Communication

Although many factors contributed to the disaster, such as the infrastructure limitations and environmental conditions, communication was arguably paramount in causing the accident. Like the pilots we often find that when colleagues work under pressure, communication is reduced to a bare minimum; "release the batch asap", "no it's done. I cleaned the line", "deviation filed", just to name a few examples. Context and metadata almost always suffer when stress and time constraints are introduced to a conversation.

Below is a transcript of the communication between the two aircraft and ATC:

ATC: Taxi to the holding position for Runway 30. Taxi into the runway. Leave the runway third to your left.

KLM: Roger, sir. Entering the runway at this time. And we go off the runway again for the beginning of Runway 30.

ATC: Correction. Taxi straight ahead, uh, for the runway. Make, uh, backtrack.

KLM: Roger, make a backtrack. KL4805 is now on the runway.

ATC: Roger.

Half a minute later

KLM: You want us to turn left at taxiway one?

ATC: Negative, negative. Taxi straight ahead, uh, up to the end of the runway. Make backtrack.

KLM: OK, sir.

PAN AM: Uh, we were instructed to contact you and also to taxi down the runway. Is that correct?

ATC: Affirmative. Taxi into the runway and, uh, leave the runway third… third to your left.

PAN AM: Third one to the left, OK.

ATC: Third one to your left.

In cockpit PAN AM:

Pilot: I think he said first

Co-pilot: I’ll ask him again.

ATC: KL4805, how many taxiway, uh, did you pass?

KLM: I think we just passed Charlie (taxiway) four now.

ATC: OK, at the end of the runway make 180 (turn completely around) and report, uh, ready for ATC clearance.

In cockpit PAN AM:

Pilot: This first (taxiway) is a 90 degree turn.

Co-pilot: Must be the third… I’ll ask him again

Pilot: We could probably go in, it’s, uh.

Co-pilot: You’ve got to make a 90 degree turn.

PAN AM: Would you confirm that you want the Clipper 1736 to turn left the third intersection?

ATC: The third one sir. One, two , third – third one.

In cockpit PAN AM:

Pilot: That’s two.

Flight engineer: Yeah. That’s the 45 (degree taxiway) there.

Co-pilot: That’s this one right there.

Pilot: Yeah, I know.

Flight engineer: Next one is almost a 45.

Pilot: But it does, it goes ahead. I think it’s gonna put us on the taxiway.

Co-pilot: Maybe he counts these as three.

KLM has turned and the pilot revs the engines.

In cockpit KLM:

First officer: Wait. We don’t have clearance.

KLM brakes.

KLM: KL 4805 is now ready for takeoff. We’re waiting for out ATC clearance.

ATC: KL 4805. You are cleared to the Papa beacon. Climb to and maintain Flight Level 90. Right turn after takeoff. Proceed with heading 040 until intercepting the 325 radial from Las Palmas VOR.

KLM proceeds with takeoff

KLM: Roger, sir, we are cleared to the Papa beacon. Flight level 90 until intercepting the 325. We’re now at takeoff.

ATC: OK. Standby for takeoff. I will call you.

PAN AM: We are still taxiing down the runway

ATC: Roger, Pan AM 1736, report the runway clear.

PAN AM: OK. Will report when we are clear.

ATC: Thank you.

In KLM cockpit:

Co-pilot: Did he not clear the runway then?

Pilot: Oh yes.

In PAN AM cockpit:

Pilot: Let’s get the hell right out of here.

Co-pilot: Yeah… he’s anxious, isn’t he?.... After he’s held us up for all this time – now he’s in a rush.

Pilot: There he is! Look at him! Goddam… that son-of-a-bitch is coming.

Co-pilot: Get off! Get off! Get off!

Communication Breakdown and its Ramifications

The Tenerife disaster underscores the catastrophic potential of communication breakdowns. The confusion over taxiway instructions and takeoff clearances amid environmental and operational pressures highlights how critical clear, unambiguous communication is in high-stakes situations.

Similarly, in the pharmaceutical industry, where the stakes involve human health and safety, communication breakdowns can lead to grave errors. For instance, misinterpretation of manufacturing instructions can result in product recalls, and unclear regulatory submissions can delay or prevent the approval of potentially life-saving medications.

Parallels to Human Error Reduction in Pharma

The pharmaceutical industry, much like aviation, operates in an environment where the margin for error is minimal. The disaster at Tenerife teaches us several key lessons applicable to human error reduction in pharma:

• Standardization of Communication: Just as aviation has adopted standardized phraseology to minimize misunderstandings, the pharmaceutical industry benefits from standardized documentation and communication protocols, especially in research, manufacturing, and quality control processes.

• Clear and Detailed Procedures: The ambiguity in the pilots' understanding of the clearance instructions parallels the need for clear, detailed SOPs in pharma. Ensuring that procedures are well-documented and unambiguous can prevent errors in the formulation, production, and distribution of pharmaceutical products.

• Training and Preparedness: Ongoing training and simulations in crisis management can prepare individuals to handle high-pressure situations more effectively. In the pharmaceutical industry, regular training on equipment, procedures, and emergency response can reduce the likelihood of errors.

• Cultural Shift Towards Safety: Cultivating a culture that prioritizes safety over speed or cost efficiency is crucial. Encouraging employees to speak up about concerns without fear of retribution can uncover potential risks before they lead to errors.

Why Good Communication May Have Prevented the Disaster

Reflecting on the Tenerife disaster, it's evident that clear, unambiguous communication between the air traffic control and the two aircraft could have prevented the tragedy. Ensuring that instructions are understood correctly, confirming crucial actions, and using standardized terminology can significantly reduce the risk of misunderstandings. Similarly, in the pharmaceutical industry, fostering effective communication channels, both internally among teams and externally with regulatory bodies, can prevent errors that compromise product quality and patient safety.

Conclusion

The Tenerife disaster serves as a poignant reminder of the devastating impact of human error, underscored by communication failures. Drawing parallels to the pharmaceutical industry, it becomes clear that the principles of clear communication, standardization, training, and a safety-first culture are universal pillars in managing human error.

By learning from past mistakes and continuously striving for improvement, industries can protect the lives of those they serve. Just as aviation has evolved in response to the lessons of Tenerife, so too can the pharmaceutical industry advance by prioritizing the reduction of human error through effective communication and robust safety protocols.