CABINsafety Beating the Odds

Review of in-flight use of automated external defibrillators yields a more realistic picture of who survives.

By Wayne Rosenkrans | From Orlando

n passenger’s sudden car- like others highlighted in this article, for those shocked by an AED within diac arrest during flight creates a emphasized practical applications of three minutes of collapse, he said. rare and stressful experience for newly available data sources. “In comparison with the passenger the responding flight attendants, MedAire’s data — representing 947 traffic, very few people die in flight,” Aand health outcomes of these events cases of in-flight use of an AED among Alves said. “The reality is that the have been significantly poorer than in receiving assistance from the industry has 0.05 deaths per billion rev- gambling casinos although automated MedLink Global Response Center — enue passenger kilometers … one death external defibrillators (AEDs) are widely showed that when the AED was used to for every 7 million passengers carried. used in both environments. Yet feedback analyze electrical activity in the victim’s MedLink deals with 4.8 in-flight deaths to crews about in-flight “saves” and heart after signs of sudden cardiac ar- every month.” deaths involving AEDs has been scarce, rest, and the synthetic voice said “shock Sudden cardiac arrest was one of says Paulo Alves, a cardiologist and vice advised,” about one-fourth survived several natural causes of these deaths; president, aviation and maritime health, long enough to obtain hospital care (Fig- it has been the most common way an MedAire. He was among the presenters ure 1). Before AEDs, this mortality rate otherwise healthy person dies outside a at the 27th International Cabin would have been 100 percent; neverthe- hospital. Ventricular fibrillation — an Safety Symposium in Orlando, Florida, less, the rate of saves documented in arrhythmia in which the heart quivers U.S., held April 27–29. His presentation, casinos has been up to about 70 percent rapidly — occurs in 70 percent of these

42 | flight safety foundation | AeroSafetyWorld | May 2010 CABINsafety

cases, Alves noted. The AED’s shock is intended was the constant surveillance of casino customers to stop the ventricular fibrillation, enabling the by security systems and officers. body to “reset” a normal heartbeat. AEDs automatically record the sequence MedAire data reflect that although ven- and timing of the first responder’s actions to tricular fibrillation most often was documented enable medical review. Alves found examples of during the earliest parts of a flight, it also may in-flight rescuers performing cardiopulmonary have involved unwitnessed collapse in the middle resuscitation (CPR) with only five to 47 chest of a long-haul flight — that is, the passenger’s compressions per minute, most often five, and loss of consciousness was not observed within excessively long pauses between sets of 13 com- three minutes by other passengers or cabin crew. pressions to give two ventilation breaths. This “Sometimes they were sleeping, so others did not was contrary to the 2005 guidance recommend- identify the collapse,” he said. “Many people who ing more than 100 compressions per minute. started feeling ill went to the aircraft lavatory “Carrying AEDs has been a historic move and collapsed there. It was also difficult to notice for the aviation industry ... something fantastic whether a person was breathing or not, especially ... and flight attendants saving lives in about 24 under low-light conditions.” The primary distinc- percent of cases has been remarkable given the tion from casinos, Alves concluded, apparently remoteness of hospital care,” Alves said. “But

In-Flight AED/Monitor Utilization, January 2001–December 2008

All uses of AED/monitor (947 cases)

Monitoring only (609; 64.3%) AED used (338; 35.7%)

No shock advised Shock advised (VF) (256; 75.7%) (82; 24.3%)

Survival to hospital (21–23; 25.6%–28.0%)

Other Other 5% Respiratory 6% 7% Crew Diabetes Nurse 14% 7% passenger 17%

Neoplasia Not reported 9% 55% Physician Cardiac passenger 16% 64%

Category of person Category of patient's who operated the AED/monitor pre-existing medical condition

AED = automated external defibrillator; VF = ventricular fibrillation Note: These in-flight medical events occurred among airlines receiving assistance from the MedLink Global Response Center. “Survival to hospital” numbers represent the range of data accuracy.

Source: MedAire

© Andrea Danti/Fotolia © Andrea Figure 1

www.flightsafety.org | AeroSafetyWorld | May 2010 | 43 CABINsafety

there are chances for improvement. We recom- CRM skills, perhaps the diversions could have mend a high level of awareness in the cabin to been averted. So we put ASAP reports under the identify victims as early as possible to deliver a microscope to determine what was happening, saving shock.” what was causing degradation of crew camara- derie and effective outcomes.” Broadening CRM action programs (ASAPs) in the Communication Breakdowns United States — voluntary, nonpunitive safety A paper on the causes and effects of recent com- reporting programs — increasingly provide munication breakdowns between flight crews insights into broader applications of crew and cabin crews will be published in mid-2010 in resource management (CRM), said Sandra the FAA International Journal of Applied Avia- Ingram, ­manager, onboard service–safety and tion Studies, said Lori Brown, the paper’s author security, United Airlines, and Vicki Jurgens, and a faculty specialist in the College of Aviation, chairperson, Safety, Health and Security Western Michigan University, U.S. “The indus- Committee, Association of Flight Attendants– try actually has added communication barriers,” Communications Workers of America, and a Brown said. “The only barrier reported to have United Airlines . been improved over the past 14 years was aircraft “CRM developed [originally] as an open- systems familiarization for cabin crew. Survey door concept,” Jurgens said. “We no longer have respondents’ main concern was obtaining an ad- an open door … and we are not sure that cur- equate preflight briefing. Many said briefings are rent CRM training goes far enough … not only only given to the purser/lead .” in the way that we handle passengers but in One respondent wrote, “Having just how we handle ourselves.” A common language, completed my annual CRM [training], I was re- safety culture and synchronization of informa- minded just how little the flight attendants know tion must be integrated across all airline systems, about what’s happening up in the front. There Ingram added, and ASAP event review com- needs to be a fundamental shift in thinking … mittees should not hesitate to delve deeply into to rebuild the relationship.” Another said, “It is flight attendant ASAP reports that may seem not uncommon, when working in the back, to insignificant by their numbers alone. have never met the flight deck crew when we fly “We have started seeing reports of incidents just one segment. That is dangerous.” involving flow of information that are making Of 224 flight attendants surveyed, 55 percent us uncomfortable, one [incident] resulted in a reported that they have been hesitant to report a diversion,” Jurgens said. “If the communication problem and 16 percent indicated that they had is flawed, we put ourselves at risk. … So we experienced a situation in which they did not have to make sure that our CRM training not report a problem to the flight deck because they Top to bottom: only touches our crew but everyone who works assumed the pilots would already know about Alves, Nesthus and with our crew.” Rifts between flight attendants the problem, Brown said. “Of 51 pilots surveyed, Karlsson and agents may result in one group or the 41 percent indicated they had situations where a other abdicating responsibility for decisions or flight attendant did not report a problem.” actions that affect safety, for example, she said. “We employ a risk ranking because we know Midway Overrun Lessons that [the issue in] any one of the ASAP reports Evacuation lessons from the December 2005 acci- has the potential for great damage,” Ingram dent in which a Boeing 737-700 overran noted. “We have had minor incidents, just a 31C at Chicago Midway (ASW, 2/08, p. personality conflict, all the way up to diversions 28) were summarized by Larry Parrigin, man- of aircraft and other significant events. If some ager, in-flight services curriculum and program

Photos: Wayne Rosenkrans Wayne Photos: of the flight attendants and pilots had used their development, Southwest Airlines. The Midway

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evacuation took an estimated five to 10 Revised training has flight atten- Free Realistic Training minutes. The collapsed nose landing dants practice adapting memorized Struggles to overcome budgetary gear caused the aircraft to come to a procedures and commands to fit the constraints and provide realistic stop in a nose-down, tail-high attitude circumstances. “In this evacuation, the recurrent-training experiences have with forward doors close to the ground. forward slides had inflated parallel to been alleviated at a small Swedish Slides at the L1 door, and the ground onto a landscaping berm,” airline through partnerships based aft doors were deployed, and aircraft res- he noted. “The flight attendants at on bartering for resources, said Anna cue and firefighting (ARFF) personnel these doors had said, ‘Come this way, Mellberg Karlsson, emergency and positioned stairs at the aft service leave everything, cross your arms and CRM instructor, Novair. “We have a door, Parrigin said. jump’ onto these slides.” Passengers hard time getting our people to a cabin “These passengers couldn’t un- could not slide down, however; they training mockup of the correct aircraft derstand what flight attendants using had to maneuver themselves along the type,” Karlsson said, a situation that megaphones were saying, so the for- slide or be lifted off the side of the slide sometimes requires explaining Airbus ward flight attendant started going back by firefighters on the ground. door operational differences while into the cabin, repeating announce- substituting a 737 mockup. ments about once every four rows,” he FAA Fatigue Research Novair’s no-cost partnerships, said. “The flight attendants did exactly The final step in a flight attendant however, have opened opportunities to as they were trained, but we found that fatigue research project, directed in experience sea survival and hyperbaric they were not holding the megaphones 2005 by the U.S. Congress, should be chamber training in cooperation with close enough to their mouths for the completed in 2010 and lead to “a look Swedish military training centers. Com- microphones to pick up what they into potential regulatory revisions,” said pany instructors also have enlisted out- were saying.” Every Southwest flight Thomas Nesthus, a research psycholo- side specialists, such as ARFF specialists attendant now practices retrieving gist in the Aerospace Human Factors who cover how they will interface with megaphones from brackets and loudly Research Division, FAA Civil Aero- the crew in an evacuation; emergency- issuing intelligible commands during space Medical Institute (CAMI). This care nurses who demonstrate patient tri- both initial training and annual recur- quantitative study of 210 flight atten- age principles and methods of stabilizing rent training, he said. dants on duty and off duty has been injured people at the scene of an aircraft The accident airplane flight at- examining “physiological and neurop- accident; and airport duty officers. tendants had been trained to wait for sychological effects, fatigue, sleepiness, “All these experiences became pos- the captain’s evacuation command if circadian rhythms and rest schedules,” sible by instructors showing interest, the cabin was intact and there was no he said. being very persuasive and exchanging apparent threat such as interior damage, “This field study is our most complex favors,” Karlsson said. “For example, we water, smoke, fumes or fire. Revised yet … and the sole source of objective lent an aircraft, a crew and instructors training emphasizes that an unusual data,” Nesthus added. “[Before] pos- to the national police force for hijack- aircraft attitude, in combination with sible revisions of regulations, we want ing scenarios.” other threats, is a valid evacuation to have … objective data saying that the Novair recently began integrating trigger after flight attendants attempt to schedules are problematic and we need refresher-training tasks into line opera- contact the flight crew. to make some changes.” As of late April, tions. “Three months before recurrent In the minutes prior to this evacua- about 175 flight attendants had com- training, pilots and flight attendants tion, one flight attendant left the assigned pleted their data collection. Data have received a document with five tasks to aft exit armed and unmanned to seek been generated by wrist-worn activity perform when time permits, requiring information about what to do. A much sensors, psychomotor vigilance tasks us- their cooperation [and mutual sign- safer action would have been to enlist a ing mobile phone–based personal digital offs] during the flight,” Karlsson said. passenger to relay information to and assistants, pedometers and other moni- “One task example was flight attendants from other flight attendants, and to tors of sleep, activity level, fatigue and entering the flight deck and operat- report and observe what was happening alertness. Data collection was scheduled ing a pilot seat to perform the pilot- outside the aircraft, Parrigin said. to be completed during May. ­incapacitation drill.” www.flightsafety.org | AeroSafetyWorld | May 2010 | 45