A tale of two pilots

By Bob Wachter

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.

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."