Mandatory Safety Reporting Feasibility Questioned

C.F. Ward

To the Editor

The suggestions in the letter (Summer 2000 APSF Newsletter) from Dr. Mychaskiw regarding mandatory safety reporting for anesthesia in a manner similar to that in the airline industry head in the right direction, to my opinion, but the devil is in the details. Everyone makes the aviation comparison but not always with detailed examination of how aviation does it. Just for example, airline pilots are paid more for flying at night, in the newest UAL contract up to $15 per hour – shouldn’t that apply to us as well?

However, the thrust of my response is to point out that aviation does have a reporting mechanism, started in 1975, but not through the NTSB, which has its hands very full investigating accidents. The reporting (ASRS-http://asrs.arc.nasa.gov/) system is directed by NASA, through a contractor(Battelle Memorial Institute) out of Moffit Field in northern California. Reporting forms are available at any local FAA office, and require that submission include information about what should have been done to eliminate or decrease the hazard. Thousands of these reports are filed and a monthly newsletter, CALLBACK (>85,000 copies) is issued every month. Frequent studies(>56) are issued by the ASRS. It has as its sole directive promoting aviation safety, through developing understanding of the interface between the system and the people in it, and has been invaluable in that regard. Why do people report events? Simple – the FAA provides amnesty for any aviation error, such as an altitude “bust,” which is not related to a crime or willful violation of the regulations, reported in a timely manner. For anesthesia, the APSF is the ideal organization to set up such a systemÑbut how do we motivate the submission of reports? Trial lawyers would contribute an amount equal to the California state budget to erase the word amnesty from the language. The aviation system works because it is cooperative and all have the same goals – everyone goes home alive. That is not the case, unfortunately, in the adversarial legal system in which we all function, where the first step after a mishap is to fix blame. Mandatory reports can be legislated, but without some form of identity cloaking or protection, they will be written in such nonspecific language as to be useless for serious purpose. Ask those at the NTSB or other aviation safety organizations, such as the U.S. Navy Safety Center in Norfolk, VA, how effective they think investigation would be without some kind of witness protection. Finally, if all else fails, consult the Fifth Amendment of the U.S. Constitution on the right to avoid self incrimination. Before the reports start arriving, the safety concept needs more than lip service from a system otherwise directed primarily toward terrorizing the employees.

C.F. Ward,
MD San Diego, CA