Protect the patient, look after each other

“In World War Two, B-17 Flying Fortress pilots would, for no apparent reason, land without lowering the undercarriage”

At a conference on ‘Human Factors’ towards the end of last year, Niall Downey, a pilot with Aer Lingus, showed delegates a photograph of the lever which controls an aircraft’s undercarriage. The handle is wheel-shaped. To raise the undercarriage, you move the lever up towards the word ‘Up’. To lower the undercarriage, you move the lever down towards the word ‘Down’. Captain Downey’s dry sense of humour was on display throughout his presentation. “We assume passengers are prone to errors too,” he said, showing a picture of the approach to the passenger exit at Belfast City Airport where, on the floor, are printed the words: “Have you collected your luggage.”

You may well laugh.

However, the apparently absurd simplicity of a control designed to be operated not by stupid people, but by highly qualified, highly skilled personnel has its roots in a series of crashes that blighted the US Air Force during World War Two, when B-17 Flying Fortress pilots would, for no apparent reason, land their planes without lowering the undercarriage, or worse; pitch their craft into the ground, killing all onboard. At the end of the war, the Air Force assigned a psychologist to investigate.

As an article in Wired magazine described recently, when he began looking at the aircraft, talking to pilots, and sitting in the cockpit, he did not see “pilot error”, he saw “design error”. Many of the critical controls felt, to the
pilots’ hand, exactly the same. The psychologist subsequently created a system of distinctively shaped knobs and levers that made it easy to distinguish all the controls of the plane merely by feel, so that there was no chance of confusion even if flying in the dark.

“By law, that ingenious bit of design – known as shape coding – still governs landing gear and wing flaps in every airplane today,” noted the article. “You couldn’t assume humans to be perfectly rational sponges for training. You had to take them as they were: distracted, confused, irrational under duress. Only by imagining them at their most limited could you design machines that wouldn’t fail them.”

You would think that this approach to design and function would pervade high-risk environments today. Captain Downey went on to show a series of shocking photographs; including identically designed labels for diamorphine hydrochloride (except one dose was 30mg, the other 5mg) and a children’s cough syrup bottle with virtually the same look as a bottle of hydrogen peroxide.

His exhortation to practitioners attending the Human Factors conference hosted by the Royal College of Physicians and Surgeons of Glasgow (see Flight time: what practitioners can learn from pilots), was to approach every patient’s treatment with two questions in mind; “Where could this go wrong?” and “What’s Plan B?” Captain Downey also urged them to consider: “What’s in it for me?” What’s in it for practitioners is that, by redesigning systems of work to benefit their wellbeing, they can reduce the incidence of mistakes which harm their patients – and result in professional censure and financial penalty.

Researchers at Trinity College Dublin and University College Dublin are building on the work on Human Factors in aviation. They have proposed interventions (1) to promote wellbeing and positive mental health among pilots while also addressing mental ill-health. They add that new roles and functions could be introduced to support the implementation of wellbeing initiatives as well as digital tools to support awareness and management of wellbeing and risk identification.

Professor Peter Brennan, consultant maxillofacial surgeon at Portsmouth Hospital NHS Trust and an expert in Human Factors, told Ireland’s Dental of meeting a pilot nine years ago – the trigger for his interest in the field – who spoke about team working, effective communication, reducing hierarchy, and workload management. It’s what practitioners can learn from pilots. As another speaker at the Human Factors conference put it: “Protect the patient, look after each other.”


  1. Cahill, J., Cullen, P. & Gaynor, K. Cogn Tech Work (2019).


Published: 14 January, 2020 at 14:14
Thank you! Your subscription has been confirmed. You'll hear from us soon.
Keep in touch
Subscribe below to be kept up-to-date when we release new issues of the magazine.