Flight attendants are far more likely today to handle in-flight medical emergencies (IFMEs) than to conduct an evacuation, fight an in-flight fire or experience other cabin safety events that require specialized training, says Helen Zienkievicz, president of Health Leaders Promoting Safety, cardiac critical care and hospice nurse practitioner, and former manager of in-flight safety for United Airlines.
Even so — based on admittedly sparse data and research findings — real-world experience among cabin crewmembers in handling an IFME tends to be rare to non-existent, she told one of the April cabin safety sessions at the World Aviation Training Conference and Tradeshow (WATS 2013) in Orlando, Florida, U.S.
The quality of “pre-event” training and “post-event” support deserve thoughtful, thorough anticipation by airlines, Zienkievicz said. Especially in cases when an IFME has an unfavorable outcome, including the death of a passenger or colleague, the cabin crewmembers involved (not to mention pilots and ground staff) can be at risk for long-lasting feelings of personal guilt without reasonable cause, she said.
“In talking with flight attendants who have been involved in serious emergencies, and particularly in [responding to] passenger deaths, my experience has been that often they may view themselves as [having] failed,” she said. “When I talked to [one] flight attendant … she was so devastated … totally blown away, until I started to talk to her about some of the statistics.
“I tried to remind her that… many of these illnesses … are progressive in nature [and symptoms in flight actually may not be sudden or new]. … Studies have shown that for somebody who has a cardiac arrest [without rapid access to advanced life support] … a fatal arrhythmia, their survival rate is somewhere between 23 and 31 percent. … It’s important that we remind our crews of that so that they don’t walk away with feelings of failure, with feelings of depression, of insomnia [from thoughts like] ‘If only I had done this, or if only I hadn’t taken that flight.’ … [An IFME] is a critical incident [as] traumatic as fighting the fire on board, dealing with a bomb threat, dealing with an evacuation.”
The rate of occurrence of IFMEs “by all accounts, seems to be on the rise,” she said. Many well-documented problems still surround the subject of consistently counting and adequately explaining IFME-related on-board deaths (Cabin Crew Safety, July–August 1999). For example, the cabin crew is not qualified to pronounce someone dead, and beyond providing appropriate care and comfort for passengers who may become aware of the event, there could be risks of an aircraft being impounded by authorities in some situations.
One observable factor has been a higher proportion of passengers traveling with acute health problems or terminal diseases, she said. Consequently, the cabin has become a place where the likelihood of IFMEs has increased but passengers’ likelihood of survival also has increased. “Our flight attendants are much better trained than they were, say, 30 to 40 years ago … so certainly we’ve seen better outcomes,” Zienkievicz said. “We have enhanced medical kits. We have companies such as MedAire that can provide support and expertise in how to manage the emergency. And we also have … telemedicine, where we actually can transmit what we are finding via [Apple] iPads and [other devices to] the ground.”
More attention to the emotional dimensions of being first responders could help make flight attendants even more effective. “Even if you have dealt with [IFMEs] 10 times, it’s still going to be a stressful situation,” she said. “While they have the training, they [also] are ‘on stage’ … trying to deal with this medical event and still dealing with maybe 200 other passengers.” There can be strong desire to convey to passengers, “No problem, we do this all the time.”
What can be most helpful — yet the aspect most difficult to teach via computer-based training/distance learning — is participating in a realistic simulation of how a real IFME might unfold, including including the possible range of outcomes and their probability. Cardiac failure, heart attack, respiratory emergencies and neurological events such as strokes make good case studies.
Realism means teaching unvarnished medical facts with data that will support the theoretical and skills training, and the emotional well-being. This includes coming to terms with the possibility of supporting and sustaining life by competently performing the skills from training, but realizing that “ultimately, they don’t necessarily have the power” over the outcome, she said.
She added that airlines should be prepared to routinely take action within one to four hours to support the entire affected crew, such as by providing a quiet private place to talk with each other, to have something to drink and make phone calls.
“[This is not a debriefing but to defuse,] help them sort of calm down from the event,” Zienkievicz said. “The other thing, if possible, is to demobilize, to help facilitate them coming from a very highly stressful, high-adrenaline state to a more relaxed state. You may not always be able to pull the crew out of service, but there may be times when it is to the benefit of everyone … to give them time to adjust.” Formal critical incident debriefing and long-term follow-up, as needed, typically are scheduled later.
Face Mask Revelations
In a separate presentation, Paul Caldwell, manager, in-flight advanced qualification program (AQP), SkyWest Airlines, said his company’s AQP program currently has approval from the U.S. Federal Aviation Administration (FAA) solely for continued qualification (CQ) flight attendant training but anticipates approval for initial new hire training within approximately a year. Meanwhile, the airline has shared with other airlines “real world numbers” and lessons learned about a few ways to improve CQ, he said. SkyWest, with roughly 2,400 flight attendants, has eight cabin safety instructors qualified to teach under AQP.
“One of the big things about AQP is that it has encouraged innovation in the way that we can train,” he said. “The goal is always to achieve the highest possible standard for our flight attendants … a more realistic training environment. … There is a heavy emphasis on crew performance and TEM [threat and error management], and the biggest component is data collection.”
The airline also is modifying its grading scale for flight attendant performance in safety training, refining what was presented at WATS 2012 (ASW, 5/12, p. 42). A score of 4 (excellent) on the four-point scale currently means no errors, a standard requiring the trainee to perform almost perfectly, correcting right away even minor errors. Unsatisfactory performance, a score of 1, creates the most concern for instructors. “Those are … an instance where they made a mistake, it affected safety, and they never corrected it — or maybe it was too late to correct it,” he said.
After the modifications are complete, what will be considered acceptable (3) or standard (2) performance basically is “they made an error, but it didn’t affect safety … and how we bring them up to standard is during the debrief,” Caldwell said. “We [also] make sure they have the knowledge required for that task.”
Data from this scoring system drew attention during 2012 to instances of unsatisfactory performance on one aspect of cardiopulmonary resuscitation (CPR) first aid training, prompting changes in both the training and the scoring. The issue was correct retrieval, assembly and use of the onboard CPR face mask, for which a flexible plastic face shield formerly had been substituted in training. Used correctly on a child or adult mannequin, the CPR face mask enables first responders to create an air seal around the victim’s nose and mouth and to give rescue breaths without direct mouth-to-mouth contact.
“Prior to 2012, we were using the CPR face shield when we conducted CPR training,” he said. “It’s disposable [so] it’s cost-effective [unlike] sanitizing [the face masks].” He focused on changes discovered in the associated AQP data when the airline changed from using the face shield to an actual CPR face mask.
“Basically, the scenario [studied was] a pregnant passenger on board who experiences chest pains and eventually goes into cardiac arrest,” Caldwell said. “Health precautions — that’s basically wear gloves, use the face [mask] — [was] one of the things that we were evaluating. So in our first quarter , we had roughly 75 flight attendant classes come through.”
“[In] the first quarter, we recognized pretty early on that we had an issue with our flight attendants either wearing gloves or utilizing the CPR face [mask] or utilizing the CPR face [mask] properly. … Roughly 60 percent of our flight attendants made an error that was never corrected or recognized. … This was an instance where, as a training department, we just were not providing the proper training. … We had 23 [face mask omission] instances and 20 instances where they weren’t using gloves. My guess is they probably didn’t do either the majority of the time.”
In view of the analysis, the FAA certificate management office worked with the airline under AQP procedures for adding pictures of the devices after the first quarter, and use of a demonstration video after the second quarter. Problems in presentation of factual information in the flight attendant manual also were addressed.
From first to second quarter, the CPR face mask performance errors “went from 23 to 14, and the gloves went from 20 to 14,” Caldwell said. By the third quarter, mask errors dropped to five and glove errors dropped to three, exemplifying relatively quick modification of cabin safety training under AQP rather than waiting for a year-end analysis of performance.
Any unusual increase in resignations by newly qualified flight attendants requires consideration not only of external reasons, but also of how cabin safety training itself may contribute, said Tiffany LaTour, manager, training curriculum program development, US Airways. “We need to keep these people so we’re creating a seamless transition to the operation,” she said. “It all starts with new-hire … indoctrination qualification training (IQT), [and] we are now the second airline to bring our new-hire program under AQP.
“In the past … they would graduate as new hires … and then go on the line. [In that system, training staff would not] see them again for a year. Nobody knows how they’re doing. Nobody knows if they made it. Did they make it to the airplane the first time? Nobody knew.”
She said that the airline’s training specialists also had “started to wonder ‘Are we losing people because we’re not doing something, or [is it] the demographic … the type of person? We don’t know. So we need to do all we have to do to make sure we are holding up our end of the bargain.”
Changes developed with input from line flight attendants were FAA-approved in April. They include a new hire–focused, quality assurance component and a six-month guided probationary period designed primarily to smooth new flight attendants’ transition to line operations and to enhance their confidence, LaTour said.
Part of the solution was to leverage communication technology for cabin safety training and provide in-flight supervisors with tablets and wireless connectivity. In addition to classroom modules and scenario-based modules in cabin simulators, more time is spent in IQT aboard aircraft, and airline base stations have become partners in training activities.
She said that the probationary program focuses on conducting formal group meetings with participating supervisors at each base to discover from new flight attendants and others what seems to have been done well in training versus what has not been done so well. This includes time with a new supervisor, in which the supervisor asks questions such as “How are you feeling? What can I do for you?”
To enhance lead (formerly called initial) operational experience under AQP, even though it requires only five hours of flying on one airplane type, the company incorporated an air transportation supervisor program. “These are the people [who] take these flight attendants out on their first operating experience,” she said. “[Air transportation supervisors] don’t fall under training, but they’re not in-flight supervisors — so they’re kind of neutral.” Essentially, most activities are repeated at intervals during the flight attendant’s first year.
For purposes of formally evaluating new flight attendants’ performance within the first six months of beginning flying, the in-flight supervisor conducts one quality assurance ride — essentially similar to the check ride, with possible punitive consequences, collecting 68-question–data points, coding every observation (safety-related only) and inserting comments. The air transportation supervisor, flying as a passenger, conducts one separate safety and procedures ride with a brief safety-related checklist, all solely for support and coaching. All of these changes have been accompanied by correspondingly upgraded training for the in-flight supervisors, including self-awareness of leadership styles and validating that quality assurance rides and coaching are consistent among different supervisors, LaTour said.
Cabin TEM Focus
JetBlue Airways has taken steps to supersede crew resource management (CRM) with TEM designed for cabin crews and has U.S. regulatory approval under its AQP, said Steve Guillian, a captain and TEM project coordinator in Inflight Training Program Development, and Jennifer Carlson, TEM curriculum developer for the College of Inflight at JetBlue University.
“The difference is that TEM is more operationalized. … TEM involves developing the actions, the tools, that we provide to our crewmembers that enable them to achieve the goals of CRM,” Carlson said. “At JetBlue we are developing TEM to replace the CRM curriculum” to identify, track and mitigate errors.
In TEM philosophy, individuals constantly need to prevent normally minor problems or errors from “snowballing into undesired or disastrous outcomes.” No single defense will be perfect. “Instead, we use as many [defenses] as possible to create a series of layers that prevent our threat from getting past,” she said. “As situations become more complicated, we need to use more defenses.”
Guillian said that the cabin crew version of TEM involves “identifying, documenting and training natural behaviors that maximize error resilience” by drawing lessons from scientific literature review and the knowledge of exceptionally skilled crewmembers.
The specific TEM skills can be summarized as: Plan ahead, use extra caution, communicate effectively, work as part of a team and manage the customer climate.
“We’ve essentially drilled down to the level of tactical actions that can be taken to achieve the defenses,” Carlson said. “The unique feature of [our TEM] toolkit … is that it includes practices for enhancing the overall customer experience. … There is an entire defense category dedicated to managing the customer climate. The tools in this category are aligned with the research [on using] service and etiquette to create a relational advantage.” For example, the emergency-related tools in the TEM toolkit include situational assertiveness that builds on the foundation of continually managing the customer climate.
“We seek to create a calm, relaxed cabin climate for the purpose of decreasing the complexity of safety tasks,” Guillian said. “When crewmembers have difficulties with customers, there’s potential for distraction. Not just in that moment, but also in the emotional afterglow of a difficult encounter.”
JetBlue in late 2012 implemented a new concept called informed evaluators — an element of its larger Insight IQ program designed to help all employees grasp the benefits of high quality operational data, said Christina Ferricks, College of Inflight training analyst, JetBlue University. Evaluators of flight attendants play a critical and integral role in the data that the airline collects on student performance, in turn influencing cabin crew performance while flying, and shaping high-level decisions about changes in training.
“Insight IQ is the ability to find and analyze relevant information to drive actions and decisions effectively,” she said, and ties into cabin safety instructor calibration. “[Calibration] allowed us to have some standardization as it relates to measuring student performance, and it lets you evaluate performance based on objective standards. … We grade [our entire] crew, not crewmembers … while they perform so calibration truly allows [us] to incorporate that. … One of the most impactful moments of our calibration was on the simulators.” The process revealed that some “checklist-minded” instructors had difficulty grading crews.
“If the student didn’t get everything [done] on the checklist, [one such evaluator] felt that the student was not successful,” Ferricks said. “We had another evaluator, at the same time, who watched the exact same [student’s] performance [and] felt that ‘a couple of little mistakes’ … didn’t mean that [the student] didn’t know it.” She noted that a generational/experience difference typically was involved.
After “healthy discussion,” the checklist-minded evaluators shifted their position. “Eventually, one by one, the ‘Aha!’ moment came to fruition — the evaluators began respecting the value of other decision-making styles and saw the benefits of meeting more in the middle,” Ferricks said. “Raising their awareness … we empower them to push back on each other a little bit. … We didn’t approach … calibration with the idea that we were going to bring generations [together in their thinking] but, really, we tried to appeal to all.”
Leveraging Face Time
Every minute of face-to-face training interaction with a flight attendant has become an extremely valuable but also costly commodity, said Larry Parrigan, manager, curriculum development for flight attendant training, Southwest Airlines. “The conversation that we’re having at Southwest Airlines right now is … very similar … to what’s going on across the industry,” Parrigan said. “[We’re asking] ‘How can we leverage the presence of the flight attendants? How are we getting the most [from the training time] of our flight attendants, and what can we do just by them being present in the classroom at a training facility that we can’t do with them at home?’”
The “essential stuff” that flight attendants perform breaks down as flight operations tasks, including communication; emergency duties; and customer service. Instead of spending a lot of time delivering fact-based information during initial training, the industry has been proposing changes to regulators. “Let’s lecture to them at home and just ‘do stuff’ in the classroom,” he said. “Our regulators have got to get on board with this.” Resistance in the United States recently was in evidence when he proposed content-rich (that is, interactive multimedia) computer-based training as part of a proposed curriculum on life rafts to be taught before flight attendants arrive for their practical training.
Parrigan said that the FAA cabin safety inspector who reviewed this proposal told him, “‘I will not sign off on a program that has a computer-based element for a subject that is new to flight attendants.’ I asked ‘Why?’ and the response was ‘This is too new. They still have questions that will require an instructor to answer.’ … We were told that we couldn’t ensure that our students were engaged, and that with an online training course, we couldn’t guarantee that our flight attendants are paying attention. [But] we could actually utilize that class time performing the tasks that the flight attendants are required to do.”
A classic example of classroom-lecture content becoming disconnected with what flight attendants actually must be able to do is a frequently failed event-management scenario for cabin decompression, Parrigan said.
“In the classroom, we drill into our flight attendants over and over again ‘What’s the first thing you do in a decompression?’ Take oxygen. … If you walk up to any flight attendant in the [airport] concourse … they would [reply], ‘Take oxygen.’ … But we put them in the operational environment, and they consistently fail to perform that motor function.”
Optimizing Class Time
In a similar vein in Sweden, economic pressures in 2012 forced reconsideration of how best to use the relatively costly time spent bringing experienced flight attendants into classroom-based recurrent training, said Anna Mellberg Karlsson, chief cabin safety and CRM instructor, Novair. “First of all, we wanted another solution to get more time for practical training,” Karlsson said. Specifically, test-taking in the classroom consumes at least 1.5 hours that could be spent on assessing the actual performance of skills; it engages students in superfluous discussions of test scores and “thoughts of why he or she failed this test” — seriously distracting attention from learning.
After switching in 2013 to online tests, which flight attendants and pilots complete anytime in the 30 days prior to coming, instructors found that “students were not half as nervous as they used to be when they showed up in the morning and the first thing that they needed to do was take the test.” She said the change, developed by Inflight Institute, also boosted participants’ confidence and performance of hands-on skills. Presenting in class an aggregation of the de-identified test scores of the specific class also enables efficient, non-threatening corrective instruction and group discussions of the practical significance.
To deal with its growing problem of student flight attendants quitting before program completion, Novair in late 2012 also required successful completion of the Inflight Institute’s online, prequalification-certificate course as part of a revised hiring process, Karlsson said. “What we experienced was a prepared and a more motivated student [and] a 100-percent success rate. … Thirty-six students graduated in November. … With the prequalification and better use of time, we are looking [to make training of] our cabin crew as real as it gets.”