Newsletter March 2021: The Black Box

‘This accident should only happen once.’ How can lessons in aviation apply to healthcare during the COVID-19 pandemic?

ROMERO GARCIA, Carolina Soledad and Andrea Brandi


Twitter: @AnesthesiArt

The virus that caused the COVID-19 disease has marked an inflecion point in the modern era, before and after coronavirus. It has been not only a health crisis but also a global crisis of science, information, economics, education, politics and ethics.

When a plane accident occurs, several task forces are set in motion. A committee is created with members of the country where the accident took place, the aviation security agency (1), the aircraft manufacturer and experts from the country where the aeroplane is registered. Evidence is collected, including all communications and also data from the last flight. The accident is completely recreated to determine the exact chain of events. The committee seeks the truth no matter what; obviously, this is a clear situation of avoidable mortality, a term we know well at the hospital too.

Generally speaking, mortality depends on many variables; in this circumstance, COVID-19 mortality depends on the detection rate of cases, the screening criteria when doing the tests, the diagnostic criteria of death by COVID-19 and the healthcare performance in every area. Isolating a country from its neighbouring nations presents many limitations, and in the long run, can only be a small piece of the puzzle. A multinational intervention with experts from each country, experts from the European Centre for Disease Prevention and Control (ECDC) and experts from China as the first ones that dealt with the outbreak could bring the best out of this tremendous historical moment that has cost so many lives. The aviation protocol establishes four sections to study the incident that could be translated into the medical field:

  1. a) The primary non-person-related findings: such as the pathogens or the environment.
  2. b) The primary person-related findings: this refers to operations and performance.
  3. c) The indirect underlying events: events that might not be evident but that played an important role in the accident.
  4. d) The direct underlying events: these are the easiest to identify and are usually the first we see.

Participation as a party in these investigations should be a privilege and will confer no rights or benefits (2) to the members involved. These reports will be published publicly, and the entire aerospace industry will benefit from the knowledge of this accident. The transcript below is from the air traffic control (ATC) of Tenerife, where two Boing 747 passenger jets crashed in 1977 leaving almost 600 dead (Figure 1).

The radio communications prior to the crash were quite confusing (3).

17 :02 :18 (Mecanician) – Third he said?

17 :02 :19 (Captain) – Three?

17 :02 :21 (Tenerife control tower) – -ird one to your left.

17 :02 :22 (Captain) – I think he said first.

17 :02 :26 (First officer) – I’ll ask him again.

17 :02 :32 (First officer) – Left turn.

Composite chart of the Boeing 747 Jet Clipper (3)


This disaster had a lasting influence on aviation and highlighted the vital importance of using standardised phraseology in radio communications, the word ‘take-off’ will be left for just one specific situation. Moving forward from this incident, the module crew resources management module was made mandatory in aviation training for pilots and cabin crew. This course, which lasts between 14-35 hours, enhances group participation and promotes awareness of behavioural attitudes and improves communication during a crisis. Human factors, safety culture, stress management, information acquisition and management, leadership, team behaviour, synergy, etc., are just some of the topics covered. What lessons can we learn in medicine safety? We don’t have to approach this with blame, but rather with the desire to find a way to avoid a new similar accident.

This action plan drives us directly to the second great crisis of this year, the crisis of data and statistics. How can we compare numbers from one country to another when there are no clear diagnostic criteria, equivocal screening indications, no standard tests, and treatment and isolation measures are continually changing? There is an urge to adhere to data unification that allows efficient and reliable management of emergent events to achieve joint success through our unified efforts. An accurate count of the number of deaths due to COVID-19 infection, which depends in part on proper death certification, is critical to ongoing public health surveillance and response (4) not only for the present but for the future of the global community.

This crisis does not only bear the COVID-19 deaths; it has impacted all of society and each and every person. Surgeries have been cancelled, transplant programs have been reduced, chemotherapy sessions have been rescheduled and consultations have been postponed. As a result, a 50% drop in segment elevation myocardial infarction (STEMI) patients coming to hospitals has been reported (5), out-hospitals cardiac arrests had worse short-term outcomes during the pandemic (6), and an increase in avoidable death by cancer is to be expected (7).

Initiatives enhancing international workforces for disease prevalence estimation have recently begun to be framed in the European Union (8) and they should be a priority for the healthcare community. Early career researchers will play a fundamental role within multidisciplinary teams to better understand and elaborate a collaborative and efficient contingency plan. We will not succeed if every time we face a challenge we start from scratch. As a global community, we shall win if we share knowledge, expertise and solutions, if we take the inspiration and the impulse from the steps colleagues have taken, together we will go further.

What if we could watch the last year as a movie starting from December 2019 in Wuhan and coming back up until today? What would we have done differently? There is just one thing we could do, and this is to put evidence-based medicine and patient safety at the core (9). Collecting and sharing data as a community will help to bring an end to this crisis faster and better. Will this wave hold the secrets of spread? Let’s open the black box and see what it is on the tape!



  1. European Union Aviation Safety Agency (EASA).
  2. https://www.easa.europa.eu/domains/safety-management/aviation-safety-reporting  (accessed August 18, 2020.)
  3. Certification of party representative. NTSB
  4. https://www.ntsb.gov/legal/Documents/NTSB_Investigation_Party_Form.pdf (accessed August 18, 2020.)
  5. Aircraft Accident Report: Pan American World Airways, Inc., Boeing 747, N747PA, Flight 845, San Francisco, California, 1977.
  6. International guidelines for certification and classification (coding) of COVID-19 as a cause of death. Based on ICD (International Statistical Classification of Disease). World Health Organization. April 2020.
  7. Roffi M, Capodanno D, Windecker S, et al. Impact of the COVID-19 pandemic on interventional cardiology practice: results of the EAPCI survey. Eurointervention 2020;16:247-250.
  8. Scquizzato T, Landoni G, Paoli A, et al. Effects of COVID-19 pandemic on out-of-hospital cardiac arrests: A systematic review. Resuscitation 2020;157:241-247.
  9. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020;21:1023-34.
  10. Novel tools for test evaluation and disease prevalence estimation (HARMONY). https://harmony-net.eu (accessed August 14, 2020.)
  11. Robinson KA, Brunnhuber K, Ciliska D, et al; Evidence-Based Research Network. Evidence-Based Research Series-Paper 1: What Evidence-Based Research is and why is it important? J Clin Epidemiol 2021;129:151-157.



Thank you to my mentor, Dr Giovanni Landoni, for providing guidance and support.

2020 ESAIC Mentorship programme.


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1 reply

Great engineers and Standards Writers defined the content of the Black Box and how it is created. I do not know if we have this for Public Health.
4 months ago

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