Avoid, trap, mitigate

Human factors training gives people strategies to deal with threats to safety and operational errors that may reduce safety margins. The framework is summarised in the title of this post ...

• Avoid - design procedures to protect against possible threats and prevent errors being made which might reduce safety margins.
• Trap - on the basis that there will be times when threats and errors nonetheless arise, design procedures so that they are identified quickly and dealt with before they have an impact on safety.
• Mitigate - on the basis that some threats and errors will not be trapped, design procedures so that people are able to intervene swiftly to correct them and reduce their impact.

Let me give an example. When flying in the UK, ten thousand feet used to be referred to as "Flight level one zero zero", and eleven thousand feet as "Flight level one one zero." A difference of one word - but if an aeroplane was asked to descend to "flight level one one zero" but incorrectly heard "one zero zero" or read that back, then it could be descending to the level of another aeroplane.

I can't go into all the protections that are in place to reduce this threat. However, let me give an example of each of the three stages.

• Avoid - the international standard changed the wording for ten thousand feet to "Flight level one hundred" - now it is very distinct from "flight level one one zero".
• Trap - in multi crew aircraft, both pilots should hear an altitude clearance, it should be read back to air traffic control, who should check the correct altitude was read back. The handling pilot should set the altitude and get confirmation from the monitoring pilot to verify that it is in accordance with the clearance.
• Mitigate - pilots are taught the fastest way to stop the aircraft from changing altitude (in an Airbus, for example, this consists of one button press on the autopilot control).

The same sort of processes apply in a healthcare context as well, as anybody who has experience of hospitals can tell. Processes are in place to avoid the possibility of giving drugs to the wrong person, making sure that the correct dose is given, and so on. This is all how safety management works.

Now, let's talk about how the government has failed to deal with the Covid-19 crisis.

• Avoiding the threat of an international pandemic would have been making sure that investment in the NHS was maintained at a level that it didn't end up starved of resources every winter, that there was no staff shortage, making sure that there were good supply chains in place. It would have meant, following Exercise Cygnus, learning and applying lessons. For ten years, the Conservative government has failed to implement processes that would AVOID the threat of this sort of pandemic becoming a problem.
• Trapping the threat could have taken place over the last ten weeks. We saw what was coming - what had happened in China, what started to unfold in Italy. We could have used that time to buy more PPE and check supplies of it, put in place international collaboration and information sharing at the very least. The government was too busy focusing on Brexit, and telling us how well prepared we were. No meaningful attempt to trap the threat was made.
• Mitigating the threat when it arrived would have meant rapid intervention, to safeguard as many people as possible. That's what New Zealand did; it's what has limited the death toll in countries like Germany and South Korea. The impact of this could have been huge. In this article, Dominic Minghella points out that two thirds of the extra deaths were probably caused by this failure to mitigate the threat in those ten days.

It's quite possible that safety professionals - for example, the pilots in an air accident, staff in an operation - may be hailed as heroes for their efforts - for example to fly a damaged aircraft away from a school, deal with a cardiac arrest, or whatever. But regardless of how an accident unfolds, it is their job as safety professionals to apply their training to try and avoid, trap and mitigate threats to their situation.

The very least that should be expected of the government is that it should be trying to safeguard the lives of the electorate. The same human factors framework - avoid, trap, mitigate threats - can be applied to government. Rather than being held to account for this, the government continues to do all sorts of things - say "there was no way we could have foreseen this" (US intelligence were aware of it last November, and the general process of avoiding the threat should have been in place anyway), distract us with Johnson (he has not taken one for the team: he got ill because he didn't observe the government's own guidelines), and keep making promises of future performance (they are "ramping up" - when will they deliver on a single target they have given?!). The media are complicit in this; too few in the media are persistently challenging the government on its performance.

In a crisis, the population has to get behind the government - where else can it go? But this government, and for that matter the US federal government, has failed its population to a greater extent than almost any other government around the world - and it is going to continue to become more apparent for some time. The fact that so many people in the UK and US don't realise just how bad will have the awful consequence of many more thousands of avoidable deaths.