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A tale of two pilots

The pilot of the US Airways flight that crash landed safely in the Hudson River earlier this month after taking off from Laguardia Airport is rightly being praised as a hero. But how significant of an accomplishment was it, really? In 1977, the pilot of a KLM flight  on the runway at Tenerife's Los Rodeos Airport faced a similar test of his decision-making skills. The outcome was very different.

When a New York policeman commandeered a chopper after receiving a
“plane down” distress call, he expected to find a Cessna or a Piper in
the river. “I never, in a million years, expected to see US Airways in
the Hudson,” said Sgt. Michael Hendrix when he reached the plane. Well, duh.

Yet
there it was, Flight 1549, and every single one of the 155 passengers
aboard the Airbus A320 was alive, albeit a bit chilly. The miracle was
attributed to a variety of technological feats – including the
“ditching button” that rapidly seals all the openings on the plane’s
underbelly – but more importantly, to quick thinking and great teamwork
on the part of pilot Chesley “Sully” Sullenberger and crew.

Turns
out that Sully wasn’t just any US Airways pilot – he was a “check
airman” who taught others how to fly and tested new pilots for
competency. In fact, a quick read of Sully’s bio
shows that he did some moonlighting (through a company called “Safety
Reliability Methods”) as a consultant to high-risk industries,
including health care. (My guess is that his business got a little boost following the crash landing.

According to SRM’s Web site, the company…



provides
management, safety, performance and reliability consulting services
that address your needs systemically using the latest techniques based
on proven principles… Whether you are in business, government,
aviation or health care, SRM has the expertise and experience to make
you the best at what you do!

Lest you think
that Sully’s training and skill made the Airbus’s happy ending
preordained, consider the tragic tale of another pilot who was equally
revered, and like Sully, taught hundreds of pilots to fly. His name was
Jacob Van Zanten, and in the 1970s, he was in charge of flight safety
for KLM’s entire fleet of 747s.Van Zanten

Coincidentally, earlier this week I happened to re-watch the extraordinary NOVA documentary
about the flight that made Van Zanten famous. This, of course, was the
tragically foreshortened 1977 flight of a KLM jumbo jet which plowed
into a Pan Am 747 on the runway at Tenerife, killing 583 passengers

I’ve written about the KLM tragedy in both Internal Bleeding and Understanding Patient Safety, so will cover only the highlights here. The error was classic Swiss cheese
(Jim Reason’s well-known mental model for serious “organizational
accidents”) – a number of small errors and unsafe conditions that came
together on March 27, 1977 to cause the worst air traffic collision of
all time. Here are just a few of the many layers of "cheese":

  • Tenerife’s
    Los Rodeos Airport was overcrowded, as a number of planes had been
    diverted from nearby Las Palmas Airport when a terrorist's bomb closed
    the airport. Therefore, the planes were stacked up on Tenerife’s tarmac
    and the air traffic controllers were overtaxed.
  • In
    the face of the traffic jam, there wasn’t room for two 747s (the KLM
    and the Pan Am) to position themselves on the runway directly, so both
    needed to do a “backtrack” – taxiing up the runway, turning around at
    the end, and then taking off. This meant that both planes were on the
    active runway simultaneously.  
  • A fog bank happened to
    settle in, limiting visibility to about 500 feet. This meant that the
    KLM crew couldn’t see the Pan Am at the end of the runway.
  • The
    combination of vague Air Traffic Control (ATC) instructions and the
    thick fog led the Pan Am crew to miss their assigned turnoff from the
    active runway.
  • Finally, the KLM crew members had
    nearly reached their “duty hours” limit – if Van Zanten didn’t get his
    plane airborne soon, they would need to rest overnight to stay within
    regulations (at substantial cost to KLM for accomodations for nearly
    350 passengers and crew). This is an early example of how a safety fix
    – limiting duty hours – can contribute to a terrible error. (Sound familiar?)

The
KLM captain, Van Zanten – who was legendary at the airline (I’ve met
people who knew him who’ve told me that he truly was an remarkable
person) – must have been getting itchy to take off. After all, he had
been diverted to the wrong airport, was nearly at his witching hour,
and the fog was getting thicker by the second. So itchy, in fact, that
at one point, he began his takeoff roll before receiving clearance from
the ATC tower. This was a complete no-no, and his co-pilot (a young
flyer whom Van Zanten had trained and certified) reminded him that the
flight had not been cleared. Van Zanten eased up on the throttle.

But, tragically, not for long.

Another
transmission came from ATC, but it broke up a bit and wasn’t heard
clearly in the KLM cockpit. The co-pilot, however, made out enough of
it to know that it had something to do with the Pan Am plane, which Van
Zanten assumed had left the runway (since he had heard the earlier ATC
instructions for it to turn off). Thinking that the ATC instructions
had cleared him for takeoff, the anxious-to-leave Van Zanten pulled on
the throttle and his 200 tons of aluminum and jet fuel began rolling
down the runway.

Referring to that fateful ATC transmission, the later report by the Spanish Secretary of Civil Aviation, said this:

On
hearing this, the KLM flight engineer asked: “Is he not clear then?”
[In other words, he was uncertain whether the Pan Am jumbo was out of
the way.] The [KLM] captain didn’t understand him and [the engineer]
repeated, “Is he not clear, that Pan American?” The captain replied
with an emphatic, “Yes” and,
perhaps, influenced by his great
prestige, making it difficult to imagine an error of this magnitude on
the part of such an expert pilot, both the co-pilot and flight engineer made no further objections. [Bracketed statements and emphasis added]

By
the time the KLM crew saw the Pan Am a few hundred yards ahead, it was
too late. Van Zanten managed to clear the ground only enough to shear
off the entire upper section of the Pan Am’s fuselage (the NOVA
broadcast's powerful dramatization of the collision is here). 
Only a few passengers and crew on the Pan Am would survive, while
everyone on the KLM died of the impact or the hellish fire that
followed.

Sully and Van Zanten were torn from the same cloth, but
Sully was lucky enough to have been born a generation later. We haven’t
heard the US Airway’s cockpit flight recorder yet, but I know that
Sully would have been listening to, and not discounting, concerns or
suggestions raised by his co-pilot after his engines flamed out. I know
this because after Tenerife, commercial aviation instituted mandatory
programs of Crew Resource Management,
in which crew members train together to improve teamwork and dampen
down the kind of hierarchies that made Van Zanten’s crewmates reluctant
to speak up (and Van Zanten reluctant to listen). I know that Sully,
like all commercial aviation pilots, had practiced simulated water
landings dozens of times. In fact, a commercial airline pilot once told
me that before takeoff, cockpit crews always review what
they'll do if the engines flame out on takeoff – despite the fact that
only the rarest pilot will experience this disaster any time in his or
her career! I also know that Sully would have been tested yearly for
competence, on a check ride. Finally, I know that all prior engine
flame outs have been thoroughly investigated by the National
Transportation Safety Board (NTSB), with the lessons learned informing
educational programs, regulations, and new technologies.

What
does this have to do with health care? How often do we and our teams
drill on management of dangerous situations (code blues, crash
C-sections, airway problems, even complex patient transports)? Close to
never. How much do we use simulation to practice our responses to these
emergencies before they happen? Except for a few early adopters,
rarely. How many of us have gone through rigorous teamwork training to
learn to better communicate with our “cabin mates” during times of
stress? Remarkably few. How often do we need to demonstrate our
continued competency in our specialty? For most board certified
physicians, about every 10 years (up from “never” 20 years ago). And
how well do we learn from our errors? Well, never mind.

As we
prepare the ticker tape for Captain Sully (as we should), we should
recall that his success was largely a product of his training and a
series of actions taken in commercial aviation – steps that made the
Swiss cheese less “holey” and created enough overlapping layers to
minimize the chances that an error or safety hazard (in this case, some
foolish birds) would lead to tragedy.

Too many of today’s
health care providers, particularly physicians, are Van Zantens. We need
to continue to work, as aviation has for the past generation, to train
our "pilots" to become Sullys.

We in health care are flying over some pretty cold rivers, each and every day.

Robert Wachter is widely regarded as a leading figure in the modern
patient safety

movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter's World."

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Denis Bartrum

Excellent synthesis for our profession.
As a private pilot and doctor in Australia I have noticed the medical profession’s reticence to follow the lead of aviation.
Learning by our mistakes unfortunately is still alive though not as “Well” as when I graduated 35 years ago.
We need more Sully like inspiration in our profession; and less territorialism and concentration on self serving medical cartels.
Denis Bartrum

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Thank you for this good topic, I was really needed it, so thank for you again And I know more information about this topic , you can found it in this file