[00:00:00] Dan: Hello and welcome back to we, not me. The podcast where we explore how humans connect to get stuff done together. I'm Dan Hammond.

[00:00:12] Pia: And I am Pia Lee.

[00:00:14] Dan: And Pia Lee, welcome. Welcome back to the world of communications. I feel, I think you have a story to tell us this your recent days.

[00:00:23] Pia: it's been, uh, a bit of a baptism by floods, you know, you moved to the country and, um, and we had biblical rains. It really was pretty huge. And so we were, like pretty much Northern new south Wales without power, without communication and without water, didn't make the toilet situation little interesting couple of days.

[00:00:46] Um, but we are, we are safe and dry, but it, it, it has been an extraordinary and, and devastating event for up here. And really interesting to live the experience with no communication, no, no outside media to have any idea what's going on, only your lived experience at the moment of going through it, and then talking to people who can get through, because we were flooded in both ways, on our road.

[00:01:13] Just the, the generosity of the community spirit has changed. Blown me away. It has been a huge, we with a big capital w e not me, uh, you know, we've had people offering their help, helping us out mending fences, you know, it could because it's, you know, it's a mess. But been incredible. 

[00:01:36] Dan: Yeah, I'm sure. Yeah, just talking to you earlier really brings home to you. What it's like to be in a disaster jet anywhere. People are suffering this all the time, aren't they? And it really, you know, you can really build some empathy for people because you don't even know what's going on. It's not easy to do anything. So, um, yeah,

[00:01:54] Pia: And, there's a lot of tension and tragedies going on around the world. People are in similar and different situations, so it's, it's a very tense time.

[00:02:02] Dan: Yeah. And I think if we look at the positive that we not me side, um, obviously Ukraine is suffering, uh, an invasion and a load, the civilians that much violence inflicted on them. But the positive of that is to see the amazing Ukrainian spirit. Again, the we, not me thing, uniting to take action and support each other, and yet that's actually spread out across Europe. You know, I've heard that the, there are, you can't recreate any lorry drivers stuck in the UK. And, uh, the British people have been really incredibly generous, taking them gifts and so on. And so, yeah, there's some heartwarming things to come out of these terrible times, I think.

[00:02:37] Pia: Yeah, absolutely.

[00:02:38] Dan: And on the subject of extracting goodness from terrible things. Our guest today did just that Martin Bromley, we'll, we'll hear from him in a moment, but his, his profession is nowhere near this as an airline pilot captain. But he had a tragic event happen to him and his family and he, instead of blaming or looking for retribution, he found a way to improve the lives of other people and save the lives of other people through his own work.

[00:03:08] So, um, it's an amazing story. So let's go in here, Martin now.

[00:03:12] 

[00:03:12] Dan: Martin, a very warm welcome to the We Not Me podcast. 

[00:03:19] Martin: Hello, Dan. Good to be here. 

[00:03:20] Dan: Thank you so much for being here. Well, it's great to to have you on the show and we will very soon hear a full introduction from you. But as you know, we first, we start by torturing our guests with a little card game. So before we do that, I'm going to ask you to choose from one of these sets of cards so that we can hear a little bit about you. I have a red pack of tricky questions and orange pack of average questions and the green pack of quite nice pleasant questions to get to know a little bit about you. Which pack would you like to choose today? 

[00:03:49] Martin: Oh go on then. In for it then. So let's go with the red card. 

[00:03:53] Pia: Oh, cheeky.

[00:03:54] Dan: we, are going to run out of red cards at this rate. Well, guests are all, so I'm so bold. So I'm going to just choose one at random. Oh, here we go. I am most embarrassed about. 

[00:04:04] Martin: Most embarrassed. My voice, bizarrely. They always say you don't like your voice. but It's something that I've always been embarrassed about.

[00:04:13] Dan: Oh interesting. What aspect of it? 

[00:04:15] Martin: I think how it sounds to me, And apparently that's quite a common thing for people. There is a bit of a joke in my industry that when we talk over a public address system, we change our voice. I don't know if that's true, but I hope it is. 

[00:04:32] Dan: That's great. Yeah. Well, excellent. Well, don't listen to this podcast, Martin. Is my advice then, but but it sounds fine to us, and it's great to have that voice on this show. So thank you for being here.

[00:04:42] Pia: And Martin, you know, it's a real delight to have you, so, and to have somebody of your status, an OBE. Very proud to have you on the show. Tell us a little bit about who you are.

[00:04:54] Martin: Well, my profession is that I'm an airline pilot. I'm a training captain for a major UK airline. And just to explain what that means. It means that I'm a regular captain. I fly. No. Planes around. with A couple of hundred, passengers on board. And I have responsibility for the safe flight and operation of that airplane and keeping every onboard, everyone on board safe but being a train captain means that I have an additional responsibility whereby I actually get the privilege of training people to fly those aircraft, I get to instruct to examine and I even get to teach our new captain. as well and within that also have a responsibility for. The Regular training and examining all of our flight crew. So flying, I guess is not only my profession. It's my passion I fly outside of work. I have instructed aerobatics in the past. And I just fly for fun. 

[00:05:51] But the other thing I do in my life is I'm a trustee for a healthcare charity, a charity that I helped found 15 years ago. And I also have a very tiny little business on the side as well where I do some public speaking. I go and talk to large organizations about the theme of making it easy to get it right. And I've, worked with international engineering firms with the police, with submariners oil industry, air traffic control, etc. 

[00:06:18] Dan: Well, it's a very, it's very diverse sort of set of activities. And Martin w your story to get to this point is a, is an interesting and powerful and in places tragic one of course. So, would you mind telling us that story? How did you come to this place where you have this particular interest in how teams operate?

[00:06:38] Martin: So Back in 2005, I'm a, an airline pilot at the time, marriage, two young children, Victoria and Adam and you know, life was pretty normal, I guess you would say. But my wife, Elaine had to go into hospital. She was healthy, but she's had some problems. She had her sinuses would often get blocked after a cold, and it got to a point where it became quite. severe. And essentially a doctor recommended that she should have surgery. to sort the problem out. And she goes into hospital, on the 29th of March 2005. But after she's anaesthetised, problems occurred, and sadly, she ended up unconscious. She never woke from the anesthetic. And five days later, I had to make the decision to switch a life support off. She died 13 days after the original attempted operation. 

[00:07:34] So, Elaine was being cared for by an experienced and neath artist and his experience assistant. They had a good plan to start off having anaesthetised Elaine to put her to sleep, if you like, the plan was to fit something called a laryngeal mask. This is like an oxygen mask, and it helps the patient keep breathing while they are sedated.

[00:07:56] The mollusk wouldn't fit though. They tried different sizes of mask. But while this was going on Elaine's oxygenation, the level of oxygen in her body, was falling. Anything below about 90% is considered critical and it fell through 75% down to 40% or lower. She's turning blue. So this is a sign of oxygen, starvation. of what's termed hypoxia.

[00:08:22] And we know that six minutes into this procedure by this stage the anaesthetist had to decided to change? tack, he'd started to try and intubate, to put a flexible tube down her airway, which is a logical thing to have been doing. His assistant had called for help and over the next couple of minutes a surgeon waiting to perform the op came in. Another neath artist came in and another. anesthetic assistant as well as two nurses. all came into the room. And What happened was the three doctors were gathered around Elaine, attempting to intubate using a variety of techniques and bits of equipment. And the other four staff, let's call them the more junior staff. the anesthetic assistants and nurses were doing some things under their own initiative, which I'll mention in a moment, but by the time we're at 10 minutes in, this has become with hindsight something called can't intubate, can't ventilate. So this is a recognized emergency in anesthesia. There's a protocol to follow to deal with this emergency. 

[00:09:26] The team are now facing a very difficult situation. Elaine is blue. She's been starved of oxygen for over six minutes and they've tried a whole series of things that have failed. But there is a protocol they can follow that will help them. The anaesthetist is very experienced regarded as diligenct and careful by his colleagues. The other surgeon, so the other anaesthetist has other skills that will help him what's termed a difficult airway. The surgeon is also highly experienced. And in fact, because of the particular skills the surgeon had, if the anesthetist struggled at this stage with what needed to come next, that particular surgeon would have been ideal to help them. And if the other form or junior staff present, three of them were all very experienced.

[00:10:15] Oh, and the other thing that's worth saying is this is an operating theater that's, well-equipped, there's nothing missing that subsequently has felt would have made a difference. So if you like, if this emergency had to happen, then arguably this is the dream place and the dream team to deal with it. But what We know actually happened, whereas at this stage, the protocols would suggest one of two options, one of which they couldn't do for medical reasons would have suggested some form of surgical access to the airway. So in other words, putting a cutting Elaine's throat performing what's called a tracheostomy, for example, and there are other options as well. But what actually happened is that the three doctors persisted with their attempts to incubate. So they had become fixated under the stress, probably and this is a normal human reaction, they became so focused on trying to get that flexible tube down Elaine's airway that they actually were not really aware of the big danger here, which was simply that she was being starved almost completely of oxygen.

[00:11:20] And they eventually got her oxygenation back up to 90% After 25 minutes. They weren't happy with the security airway. They fiddled around and thirty-five minutes. in. They decide that They're going to let her wake up naturally and abandon the operation. Now at this point, it's worth saying, that I don't think any of you need to be doctors or nurses to understand that if you starve somebody of oxygen completely for over 20 minutes, then that person is highly unlikely to survive. And when we looked there was we had The report, the independent review, we then had an inquest as well, and the inquest allowed me the opportunity to ask some further questions to build on the report. But in his own words what happened is the lead anaesthetist basically said he lost control. There was a dispute in the inquest about who people in the team. felt was in charge at different points about what was happening. The, the understanding amongst the three doctors of what was happening, what it meant, and what needed to happen wasn't shared. Well, I term in my industry, situational awareness, the big picture was not the same for the three doctors.

[00:12:35] At the decision-making we've already mentioned it became fixated, which meant they didn't even think about the protocol, they never used the protocol. or mentioned it at all. And the communication amongst the doctors tried out. But when you look at the team around them, the more junior team, they were literally a metaphorically standing back. So they were able to observe and see what was happening. And in fact, they had a very good idea of what was going on. So when that six minute point the assistant called for help, she asked her colleague to bring in the tracheotomy tray. When one of the nurses came in, she saw Elaine's color, she saw. vital signs instinctively. She knew this was serious. She went out phoned intensive care, came back in and announced to the doctors that our bed was available in intensive care. And to quote from the inquest, they looked at her as if, to say, what's wrong? You're overreact. And in fact at the inquest. Two of the four more junior staff stated categorically they knew exactly. what needed to happen, but didn't know how to broach the subject.

[00:13:41] So here we had a situation where the people who were making the key decisions and actions were really unaware of what the problems and issues were yet. the wider team were very aware but were simply unable to get that message across. So in effect, we had a team of people that were actually a team of individuals who couldn't work together. who couldn't support each other.

[00:14:10] And I, I really just think it's important to say that the one thing I've I will not do is criticize them. Because actually when I started to look at the culture in health care, I discovered that the reality was they delivered what the system would have had them deliver, because they didn't have the sort of education and learning that I have in my industry about how to work as a team how to behave as a team. And even worse than that, they didn't have the processes and practices that meant that doing things that might have stopped this, getting to that point, or that might've helped interventions, those processes, protocols, and the culture of doing that simply didn't exist.

[00:14:52] Pia: Listening to you, Martin, I feel like I'm almost in that operating theater, listening to it. It's incredibly graphic. And I still think there's a part of me that is just quite stunned by your magnanimous conscious choice, not to make somebody pay you. How did you come to terms with this. To really go on a course of action over the last 17 years that, that, you know, has striven to those to make this, overcome this in the whole National Health Service. I mean, I think there's something like 12,000 avoidable deaths per year in the UK hospitals?

[00:15:36] Martin: Yeah, the, something like that, the figures are always in dispute, but the reality is that. we know, and this is Internationally. So it doesn't matter where you are in the developed world as you might term it, is that the, we know that errors and incidents impact patients about in 10% of time that you are interacting with health care. And that's been found in all sorts of international studies. So every time you interact with healthcare, whether it's collecting medicines, whether it's getting appointments arranged, whether it's having a surgery or being reviewed by a mental health practitioner, we know that about 10% of the time and error will occur.

[00:16:14] There's a lovely quote from Dr, sorry, Professor Lucien Leape at Harvard who did a study, and he said, I'm just going to quote you here, for one patient in every 300 entering hospital in the developed world, medical error results in or hastens death. So one in 300 is a really significant stat.

[00:16:35] But for me in answer to your question, this was about how do I stop this happening to other people. Elaine was dead and it didn't matter what I did that wasn't going to change. But I could maybe make the system better. And logically the only way to do that was to understand why, it made sense at the time. 

[00:16:57] And when you look at the training that the doctors and nurses and allied health professionals, have, it's very tense. It's not about how humans behave under pressure. It's not about how you can behave in a way That helps a team work well together. It's not about how you can behave that improves leadership. It's all about the technicalities of the patient, the equipment, the condition, and all that sort of stuff. And there's an historical reason for that. When you look at how healthcare has developed over the last few centuries. 

[00:17:30] But in essence in, in aviation, for example, you know, we've got a relatively short history of a hundred or so years. And we're what we do these days is we look at accidents and incidents and safety reports And we look at what happens in a simulator, when people perhaps are learning something new and either struggling or find it easy. And that provides an evidence base of what are the behaviors that seem to make it easily. To get it right. And What are the behaviors? that seem to lead to bad outcomes. And so what we have is a list. If you like of behaviors and areas of competence that we know don't necessarily lead to success or an accident but we know that in successes and in failures, certain behaviors are more or less present.

[00:18:20] And so my focus I talk to organizations and talk to health care about teamwork. For example, is very much focusing on behaviors and what are the specific behaviors you can use that make it easy for your team to get it right. 

[00:18:34] Pia: Martin, you talked about there's these high levels of technical expertise, but it seems to be some of the human factors that can create these accidents. The aviation industry has learned these lessons probably are ahead of the health industry.

[00:18:50] Martin: So I think it's important to say, first of all that what we've learned in aviation very early on was that technically we needed to be better at what we did. Technically the aircraft needed to be better designed, better built, and technology has dramatically improved safety. But particularly as we got into the sixties and seventies, aircraft were becoming much safer, much more reliable, but accidents were still happening. And United 173 was a good example and it was probably the accident that really gave the biggest boost to our understanding of the human in the flight deck.

[00:19:25] So United 173 was a relatively small American jet airliner. It was a DC eight. It was flying an internal flight to Portland in Oregon. And this was in December, 1978. Unfortunately, when they were about to start their approach to land, they went to put the undercarriage down the guilt. And the indications that they got in the flight deck suggested that there might be a problem that a couple of the the wheels were not in the right place.

[00:19:56] Now, what they did very carefully is they stopped the approach, they went into a holding pattern and they worked for all the manuals and worked out in fact that the wheels were almost certainly in the correct position now, and it was safe to leave. Now at that point, you might have thought great, they can now land. But in fact, what happened is that the crew carried on circling for about another 40 minutes until they ran out of fuel and they ended up crashing in a suburb of Portland. Amazingly, nobody on the ground was killed, sadly a number of people on the aircraft.

[00:20:36] Now when the accident investigators looked at this, they found that the crew had had ceased to function as a team. So the captain had become fixated on that particular case in the potential gear problem, even though the checklist suggested that the gear was now safe. And all the kind of possibilities that might happen and how they can prepare for the landing that would eventually happen. Meanwhile, the engineer and the first officer were watching the fuel going down and they were trying to get the message across, but not as directly as they perhaps could have done. So the message never really got through to the captain until in fact, one of the four engines flamed out because of less loss of fuel. And eventually as they, at that point, then turn towards the airfields, try and get on the ground quickly. The other engines flamed out in quick succession, and it was simply too late.

[00:21:30] And so in essence, what we had here was an aircraft that had a minor technical issue that was safe to land yet because of the way in which it was managed in the flight deck, what was a minor technical issue, became a disaster. And that really led the work around understanding teamwork in aviation and in the report, the American NTSB talked about the need for participative management. Whether you like the term or not, the reality is that started the journey that we've been on an aviation since 1978. and a number of key writers in Leslie and Matthew Syed for example, have made the reference to United 173 and to my late wife's case as being very similar in how they ended up and what caused them.

[00:22:17] Dan: so, there's definitely, you can see the similarities starting to come in. you probably been forensic about this and you've, you're two worlds come together in this. If we look at these two points of failure, what is it in the human factors that caused these things to happen?

[00:22:36] Martin: Yeah, so. I want to emphasize, first of all that systems are important. So when I talk about systems, I don't mean necessarily IT systems or high tech. What I mean is the procedures and protocols and ways of working. If you like, what we term, the standard operating procedures are important. So for example, in aviation, one of our standard operating procedures is we brief before we take off, before we land on every single time we fly, and we're doing that to understand the potential threats and potential errors and how we might deal with those. Now in Elaine's case and in healthcare, generally, that sort of briefing is unheard of, but it is about other systems as well. And you can have technology, for example, that reduce the probability of human error. So in healthcare, for example, we see electronic prescribing where electronic systems can keep track of your prescriptions and make sure they're delivered safely, et cetera. But of course they're still not perfect. They still require an element of human input. 

[00:23:47] So systems are critical, but behaviors are also critical. If you've got a good system, you still need behaviors that support that. So we've talked about the standard operating procedures that make it easier to get it right. So we're talking about behaviors, for example, I've mentioned briefing, so anticipation is a very important behavior for a team to adopt. So this is about your briefing about what you're about to do. It's about considering threats and errors that might affect what you're about to do. And it doesn't matter what team you're in. Whether you're in an insurance company, whether you're in an aviation company, just before you start something, just making sure everybody's clear and everybody's thought through what may happen with whatever it is you're about to do. It's about mental rehearsal. It's about simulation. It's about training. You know, if you run an organization of any sword, you can't expect good teamwork. If people aren't trained in the basics, not just of teamwork, but actually of doing their job, so you need to make sure that people are competent before you get into the details and the teamwork. And that's anticipation is all about building an understanding so that you can think ahead and trading supports that. 

[00:25:05] The second thing is about having a, an open style. So specifically United 1 73, I mentioned participative management. So an open style is this ability to, as a leader to ask an open question. And it's literally just that. And then sitting back and listening. So we, we spent a lot of time in aviation with this. So for example, if I'm flying and something technical happens and there's maybe a fault in a system, I might be sitting there as a very experienced pilot thinking, oh, I know exactly what that is. I know exactly how to fix that. All we do is this and this. But what I actually do is I will turn to my colleagues and say, Okay, so, what's happening? Or I might say any ideas Or have you seen this before? Or how would you approach this?

[00:25:55] Pia: You're inviting input. 

[00:25:57] Martin: Inviting input, absolutely. So, so then while people are then sharing their thoughts with me, it means the first of all I now have cognitive capacity to sit and listen and think because I might have an idea, but there's a high probability that simply by listening to their ideas, it might make my idea even better. In other words, not just, we don't want just people to come up with a solution, we want them to come up with an optimum solution. And th they do bear in mind that, you know, aircraft are very complicated and there are many things happening. Healthcare is very complicated. There are many things, and actually most jobs, these days are very complicated. So no matter how experienced technically you are, you won't have all the perspectives.

[00:26:40] But the other thing about this is I might've seen something happen. And I might ask my team, you know, what's your thoughts on that? And they might say, well, X, Y, and Z. And I think, well, Hey, can I sit in there thinking, hang on a minute. No, that's not what I saw. I thought it was ABC. And they're saying it's X, Y, and Z. And in fact it might be that I've actually not perceived what's going on. And that was certainly true in my late wife's case.

[00:27:04] So, so this really is a different way of thinking. And when I work with leaders, for instance, we'll talk about open questions and they say yeah, I do that, absolutely. But then when you watch them, what'll happen is somebody will come into an office and say, hey boss, we've got a bit of an issue here. And the boss says, okay, so how do you think we should deal with that? And then the person goes quiet for a moment. And the boss says, well, I mean, for example, we could do this and we could do that, or we could do this, but that's perhaps not such a bad idea. Anyway. What do you think? And inevitably the person says, well, yeah, I suppose we could do what you think, yeah. 

[00:27:38] Dan: I think I think what you think, yeah.

[00:27:40] Martin: And, you know, I spoke to a colleague who works in intensive care in London hospital, and he's been using this style. And he said to me, you know, this is amazing when you use it. He said, because first of all, it creates the cognitive capacity. I can sit and listen to the nurses and my doctor colleagues around me, and I can formulate an opinion that a decision that I think is much better, he said. But not only that you said, what I've noticed is since I tried doing this, I've noticed that for example, Junior staff will come up to me and say, hey mark, have you thought about this? And I didn't even ask them a question. It's creating the culture and it's sending out the behavioral message that says, I am open to ideas. I want to listen. And that is the really valuable thing about having an open style.

[00:28:26] I should just say about that by the way. When I talk about that in healthcare, a lot of people say, oh, I totally agree with asking open questions. It's good because it helps the junior people learn. Now that might be true, but that is taking completely the wrong attitude. it's that is a kind of a, that's driven for a point of ego. No, it's about helping you learn as well as other people learn. 

[00:28:51] But yeah, the third thing I was going to say that is also that we also teach with teamwork is that when something unusual happens, when something unexpected happens, slow down. Pause. There's very few things in aviation, very few things in health care and other safety, critical industries that when they happen, you must immediately react. And for many things, even on quite a time critical situation, just taking a moment, taking a deep breath, even counting. It's a good way. The military sometimes talk about tactical breathing, just giving yourself a moment to mentally catch up.

[00:29:31] And actually a question at that point is always good as well, turning to your colleagues and saying what the hell just happened? Can just slow that pace down. And there's a great bit of work done by Joseph leDoux, a professor in New York, back in the late nineties and put into a wonderful book by Dr steve Peters called The Chimp Paradox. And it, the idea is that we have this internal Chimp inside us that wants to react and it reacts quicker than the human. But generally what we find in safety critical industries is reacting. Hey. Repented leisure. And that's true in businesses as well. Just take a moment.

[00:30:06] Dan: Thank you. It's a lovely set of principles for any team, actually. Martin, what, this might be slightly harsh, cause these are the sort of, we've asked you for the causes of some of these problems or the, um, but what's the cause of those, if you put your finger on anything at the root causes why don't people do that? Because I'm sure a lot of. people are listening saying, well, like, yes, I anticipated and that sounds good, yes I have an open style, as you say. And I, I can do, I can ask questions and then, oh yeah, I'll slow down. What, what else is there in us as humans that prevents that or in the environment we're in that tends to those happening? What are the breaks on those, those things?. 

[00:30:41] Martin: You know what, there's an element of human nature. So particularly when it comes to quick reactions, that's the kind of fight or flight that's part of us. And that can be a very powerful thing and often a really good thing to have. So for example, if you know, and we've seen a lot of this recently, sadly, you know, if you're walking down the street and suddenly you see somebody running towards you with a knife, your fight or flight will kick in and you'll probably run very quickly the other direction without thinking. So that the temporary action is very powerful, but the problem is most things we deal with in society and teams are complex. And there isn't one simple answer to one simple problem. There are multiple consequences and an unknown consequences that we need as a team and a complex system to understand. And the vast majority of people listening to this will work in a complex system.

[00:31:35] But the other thing is that the systems that we work within often make it hard to get it right, and they encourage certain behaviors. And one of the things that I've found in medical practice is that humility is not appreciated. The system uh, looks for people and encourages this kind of confidence and says, you know, we give you five years in medical school. We expect you to know the knowledge you were when you left school, you know, I grades everything you did, that's why we recruited you. So why are you stupid? Why can't you work out this problem? We expect you to know more. So humility is frowned upon. 

[00:32:19] And then the argument is by the way that patients like confidence or there's a certain element to that. But I have to say as a patient, I feel much better when a doctor says to me, you know what, Martin, I don't know what the issue is, but I want to help find it. Because then I know that I'm dealing with somebody who's being authentic. And humility in healthcare. As I say, as almost being trained out. 

[00:32:42] There is a concept and an Adam Grant the American psychologist and a colleague of mine as well, we use this phrase about confident, humility, the ability to say to people, you know what? I've not seen this before. So tell me what you think is going on or to say, I don't know what's happening here, but I'm going to try and find out, so this is how we're going to do it. That's confident humility. And I think that's so valuable in everything we do.

[00:33:09] I can honestly say I've in the years I've worked with pilots, doctors and people in other industries, what I've really learned is that confidence and competence are not the same thing 

[00:33:23] Pia: And I wanted to ask you Martin, in the last 15 years, since you've really sort of specifically worked on, I don't, you know, like a crusade in the industry, have you, have you found yourself in a situation in the aviation side of things where you thought, oh my God, all these I've come to a critical put these into, into play. Have you found yourself? In a similar situation where you've, you've really had to practice what you're, if you've been on the human side of it, I suppose, is what I'm saying. 

[00:33:55] Martin: So I think what I've learned from health care is compassion. It's about understanding where somebody is coming from. And it's actually the phrase, you know, why did it make sense at the time? I think that's very important to understand that, but in answer to you more directly, your question. So I think what you're saying is have I been involved in a situation where I've really had to bring out these skills and all that sort of stuff? And the answer is yeah, probably, but the reality is that you need to use these skills all the time. It needs to be habitual. You can't expect to go into a critical incident and behave in the sorts of ways I've described, if you don't behave that when things are going easy and well. So these behaviors just need to be the norm because that way it often prevents the problem occurring and where we're, you know, in aviation, we're a great believer in this idea of avoid trap, mitigate, the idea that when a problem occurs, you are mitigating already. But what you want to do is to attract that problem early enough, and even better to have avoided it before it even happened. And so these behaviors need to become second nature. 

[00:35:08] But yeah, certainly in the simulator, I've had plenty of times when I'm using these skills. I'm also training other people to use these skills, but, day-to-day, I'm using them as well because if I didn't I would probably feel a lot less safe than I, than I am.

[00:35:22] Pia: That's a brilliant answer, and I think what a huge lesson for all of us out of this is not to wait for the critical incident, but to make it a standard practice in every way that we behave in all aspects.

[00:35:34] Martin: And it's about priming the team, I suppose. So they get used to a way of behaving and role modeling that, as well.

[00:35:42] Dan: I think that we often, as leaders think it's all about what we have to do and actually sometimes forget to actually build that little unit around us who have similar approaches. So I think that's a wonderful way to really land on the end on the teams. And Martin, it's been a pleasure and an honor to have you on we, not me today. I think that your story of. Taking a tragic event and turning into something that can save others and improve the world is truly inspiring. And you've managed to turn that into really practical lessons. I'm sure people want to listen to the podcast a couple of times to extract the juice, but I hope this can be part of your mission as well. So we're delighted to have had you on the show, but also to support what you're trying to do. Thank you so much. 

[00:36:25] Martin: Thank you both. Really appreciated it. 

[00:36:27] Pia: I I read an article in the New Statesman, about Martin and about this story. And he came up with a really interesting quote saying that like, like achievement. Accidents are a team effort. And it's this combination that he pulled out of this fixation error, you know, there's this fixation around I'm, I'm the expert.

[00:36:52] I've got to have all the answers. And, and then combining that with this time perception thinking somehow just losing the fact, and this is what happened, you know, with the United airlines example, just. Twig that actually there's a limited amount of time because you've got limited amount of fuel, which you'd think would be a basic, but that fixation narrowed that time perception.

[00:37:17] And then the hierarchy is, you know, questioning the boss. You know, we all questioning somebody that you think is in a more superior role and it's making an assumption. They know exactly what to do when they might not be knowing what to do. 

[00:37:30] Dan: And you could see that actually specifically in the tragic story of, um, Marty's late wife, where he said that they, the other, the juniors on the team. So, and even that in hockey, it's quite an interesting bit of language, but the juniors didn't know how to communicate. They didn't know how to get their message across ,was exactly what he said. And you think they're in the same room. And I think it does really question, are they a team, or are the juniors over here and actually, you know, we into the hierarchy point we're the experts, we've got this and if anyone on the team doesn't know how to get the message across your, your teamwork is really fragmenting. You're not really together. And it's, I think that might be the first thing is to say, we're all in this and you all have permission to, um, to say something

[00:38:17] Pia: Otherwise, there is no teamwork. Really.

[00:38:19] Dan: Exactly. And they would probably the, the consultant's mind we work as a team and the nurses might work in team, but that's two teams. Um, and they couldn't really communicate. And it really occurred to me though. I can really get this. Uh, you can imagine, I think that the emergencies and accidents seem to drive ourselves to do the, exactly the wrong things. As you say, those things that you talked about, the, the fixation, the time perception and the going for hierarchy, they are the opposite of what's needed. And, and there's a huge step that needs to be made by us. When we find ourselves in this is to say, right, actually I need to do the opposite of what my Chimp brain is, is trying to, trying to get me to do.

[00:39:02] And then you can see the. You can see that. Absolutely. And it's easy to look from the outside, but I'm sure we'd all be challenged to do those, to do the opposite.

[00:39:10] Pia: I think that would definitely definitely happen. It reminds me of Dad's Army and the guy that was used to say don't panic, don't panic. And that's what your brain is.

[00:39:18] Dan: Captain Mannering.

[00:39:20] Pia: That's what your brain's doing at that point, but I think that that trying to have the antithesis of that through anticipation that there can be challenges and those open questions and having that climate for that, that's your insurance policy to make sure that these things don't happen.

[00:39:37] And I think there's some really valuable lessons to be taken from, from the aviation industry, because it's a costly mistake.

[00:39:44] Dan: Yeah. I know that that openness really jumped out for me. I actually wrote a little piece about it this week. Having heard Martin and sort of that open style. Yes. Ask open questions, but actually in a way it's about a bit, not about the doing of openness. It's about the being of openness, you know, he said, oh, that was quite funny. People say, yeah, I'd like to ask open questions because it helps the juniors to learn. Um, and he's. No it's about helping you to learn. I thought that was a really telling, I think we can all easily fall into that trap, but, but really aren't being open, um, rather than just doing open was, was a big takeaway for me.

[00:40:17] So, um, wow. What a huge episode. That was an amazing learning for everyone that could genuinely save a life, so wonderful that Martin on the show. Absolutely brilliant. 

[00:40:26] And next week, we have James Prior, who is the, um, he was the head of leadership at Gilliad, and James always has something interesting to say. He does a lot of thinking, a lot of writing, a lot of teaching in the world of leadership and, uh, yeah, he'll have a fresh perspective on teams and the roles that people can play in that

[00:40:46] so can't wait to, uh, to hear James, uh, in the coming up. But that Pia is it for this episode. You can all find show notes and resources at Squadify dot net. Just click on the We Not Me podcast link. If you've enjoyed the show, please share the love and recommend it to your friends. We Not Me is produced by Mark Steadman of Origin. Thank you so much for listening. It's goodbye from me

[00:41:10] Pia: And it's goodbye from me.