The Black Box: Aviation, Anesthesia, and the Debt We Owe Those Who Came Before Us

Excerpts of cockpit voice recorder transcript,
Air Florida Flight 90, January 13, 1982

Aircraft: Boeing 737-222B

Pilot: Captain Larry Wheaton, age 34
First Officer: Roger Alan Pettit, age 31

Initial complement: 74 passengers, 5 crew members
Weather: blizzard with severe icing

Portion of take-off checklist:
(Pettit): Air conditioning and pressurization?
(Wheaton): Set.
(Pettit): Engine anti-ice?
(Wheaton): Off.

15:59:24 (Control Tower): Palm 90 cleared for takeoff.
15:59:28 (Control Tower): No delay on departure if you will, traffic's two and a half out for the runway.
15:59:32 (Wheaton): Okay, your throttles.
15:59:35: [Sound of engine spool-up]
15:59:49 (Wheaton): Holler if you need the wipers.
15:59:51 (Wheaton): It's spooled. Real cold, real cold.
15:59:58 (Pettit): God, look at that thing. That don't seem right, does it? Uh, that's not right
16:00:09 (Wheaton): Yes it is, there's eighty
16:00:10 (Pettit): Naw, I don't think that's right. Ah, maybe it is.
16:00:21 (Wheaton): Hundred and twenty.
16:00:23 (Pettit): I don't know...
16:00:31 (Wheaton): Vee-one. Easy, vee-two
16:00:39: [Sound of stickshaker starts.]
16:00:41 (Control Tower): Palm 90 contact departure control.
16:00:45 (Wheaton): Forward, forward, easy. We only want five hundred.
16:00:48 (Wheaton): Come on forward....forward, just barely climb.
16:00:59 (Wheaton): Stalling, we're falling!
16:01:00 (Pettit): Larry...We're going down, Larry....
16:01:01 (Wheaton): I know it.
16:01:01: [Sound of impact.]

The plane hit the 14th Street Bridge across the Potomac River and killed four motorists in addition to 74 on board. Only a minute and 37 seconds had passed from the time the tower cleared the plane for take-off to the time it crashed.


***

I don't like flying. I've been doing it almost all my life, since the age of four. But to this day as we take off in jets making that graceful upward angle I so love to watch from the ground, I think to myself, even though I can use physics to come up with the answer, "How on earth is this huge thing gonna get up and stay up?"

It's probably one of my life's greatest ironies, then, that I am an anesthesiologist by profession. Anesthesia owes a great deal to aviation for the safety measures that have now become the standard of practice, and there are several significant parallels between life in the cockpit and life behind the drape. [Click here for a great article on a play, Charlie Victor Romeo, that dramatizes this very subject and the impact it has had on medical professionals - hat tip to Transor Z for the link.]

Here are several that come to mind:

• We (pilots and anesthesiologists) must function as part of high-performance teams with high stakes: if we mess up, people die.
• We have to use technology with a great degree of skill and accuracy.
• Our work environments are complex and potentially unpredictable.
• High stress, dangerous work, fatigue, and potential disaster are ever-present issues in our line of work.
• We value and use checklists, monitors, safety protocols known to the entire team, detailed plans, backup plans, closed-loop communication, and in-depth error analysis.
• Take-off and landing are often considered most perilous times but we have to be prepared for turbulence in the middle as well.

As residents one of the most valuable educational experiences we had was training in a simulator. Practicing clinical responses to patient problems was useful but I think an even greater impact was made by the team-communication training we got in the sim. The "surgeon-as-captain-of-the-ship" model was rejected as outdated and, frankly, unsafe. Scrub techs, students, and circulating nurses were encouraged to ask questions and speak up in the name of patient safety, and all team members were expected to listen to one another, value each other's different skills, and combine them smoothly and efficiently.

One of the best tools we took from our simulator exercises was the "Advocacy/Inquiry" model of communication, which was held up as the paradigm for any person, from custodian to surgeon, who needed to express a strong concern. For example, if a surgeon noticed a drop in the patient's oxygen saturation and felt the need to confront the anesthesiologist, instead of saying, "What the heck are you doing to my patient?" he or she was taught to communicate concern for a shared patient with language like, "I'm noticing our patient's de-satting quite a bit (advocacy). What do you need me to do (inquiry)?" It may sound like touchy-feely psychobabble, but I'm telling you, it WORKS when used consistently to achieve coordinated and productive team efforts.



One of the hardest things to face, in real life certainly but even in the simulator, is error. There are so many different ways in which we err, and we all seem to err in some similar ways. We see signs of danger or doom, or get that nagging gut feeling, but we ignore the signs, or wish them away, or talk ourselves out of paying attention to them with wishful thoughts. We second-guess ourselves. We persist with a preconceived notion and try to fit all the evidence to that one idea at the risk of missing the real cause of a problem. We let an authority figure discourage us from taking a strong stand or "sticking to our guns." We see something bad on a monitor and do nothing, or do a lot without any real purpose. We fail to see what's right in front of us. We skip steps, either because we have not done a procedure often enough, or because we have done it so many times we could do it in our sleep. We forget or neglect to "follow the rules." Or, we fail to break the rules when needed.

Both novices AND experts commit the above types of errors. In addition to the use of checklists, safety protocols, and recognition of interdependent skills from different team members, one other fruitful legacy from the aviation industry is error analysis directed toward crisis management and disaster prevention rather than toward blame and punishment.

So what happened with Air Florida Flight 90?

• The pilots failed to switch on the engines' internal anti-icing equipment - a skipped step / failure to adhere to established protocols, perhaps.
• They used reverse thrust to leave the gate prior to take-off, which sucked large amounts of snow and ice into the engines in the setting of a failure to activate engine anti-ice.
• They failed to abort takeoff per FAA regulations even though snow and ice build-up were visible on the wings and a power problem was detected while taxiing.
• The first officer tried to express his misgivings, but then backed down, more than once; meanwhile, tragically, the captain failed to listen to and in-fact down-played his concerns, and insisted on "willing" his instrument readings to be heading in the right direction when in fact ice buildup on the probe measuring engine power was causing false readings.

One of the first videos we had to watch as anesthesia residents going into the simulator for the first time was a reenactment of an aviation disaster, with the actual cockpit voice recording in the background, impact-crunch and all. It was sobering. [See here for transcripts from various aviation disasters - even just reading them without hearing them can produce that pit in your stomach.] We take our jobs in our own cockpits very seriously because we have a healthy respect for the dark horror of that crunch and know well how what we do, or fail to do, can lead a patient down that fatal road. We're constantly judging ourselves, planning, double- and triple-planning, and de-briefing, trying to figure out how we could have avoided a particular problem or made some other thing better or smoother. And we have our colleagues in aviation to thank, in part, for that obsession with safety.

So when the de-icing team delayed our flight a bit to spray the wings of our tiny jet from Boston to DC with their de-icing stuff, and when the larger jet from Charlotte to San Francisco taxied BACK to the gate because the pilot heeded a warning light just after being told by the tower that he was number one for take-off, I was not annoyed in the least, as I might have been before my anesthesia days. Thanks for seeing the light, I wanted to say to him, and for paying attention. For listening to that nagging inner whisper, instead of brushing it off as "probably nothing anyway." It might just have been the tiny, meticulous move that made all the difference. It reminded me that even our smallest acts can hold unseen, great value - which is one of the things I love most about my work.
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Addendum 1/16/09: In light of all the above thoughts, Captain Chesley B. "Sully" Sullenberger is my new hero. Read here how his training, experience, judgment, and skill saved lives - or better yet, listen here (while watching an animated recreation) to the actual conversation between the pilot and the air traffic controllers just before the plane went down.