Patient Safety and a Tale of Two Pilots: US Airway’s Sullenberger and KLM’s Van Zanten

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 healthcare. (My guess is that his business got a little boost this week.) According to SRM’s website, 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 healthcare? 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 healthcare 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.

Because we in healthcare are flying over some pretty cold rivers, each and every day.

8 Responses to “Patient Safety and a Tale of Two Pilots: US Airway’s Sullenberger and KLM’s Van Zanten”

  1. menoalittle January 17, 2009 at 8:06 pm #

    Bob.

    This is a particularly pertinent perspective. There are enumerable physicians who are “Sullys”. Regretfully, they are oft marginalized or terrorized by the “Van Zanten” rulers in the C-suites, and in cases of advanced “Sullydom”, have been deemed “disruptive” to the flight management of the “jet”. You know where that goes.

    Alas, in the past two weeks, C-suite folks’ insufficient attempts at safety, using unapproved and untested HIT devices and ignoring the opinions and reports of patient endangerment by “Sullys” (and not voluntarily reporting adverse incidents themselves), are being exposed by academicians:

    http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572

    and brilliant investigative reporting is exposing the cover-ups of the safety breaches by C-suiters:

    http://www.google.com/hostednews/ap/article/ALeqM5hzWcaC_f76P1tpPibAn0aRA83TLQD95N3VOO2

    http://www.cbsnews.com/stories/2009/01/14/national/main4720942.shtml?source=RSSattr=U.S._4720942

    Finally, there is a warning about the unfettered use of HIT from The Joint Commission:

    http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

    I salute the real extraordinary Sully and the “Sullys” of our profession for equanimity and precise judgment under duress and for standing up for what is right for our patients.

    Best regards,

    Menoalittle

  2. David January 18, 2009 at 4:48 pm #

    This post reminded me of Malcolm Gladwell’s newest title, Outliers has a lot written about airline errors as well. He also mentions the list of small errors adding up to major crashes.

  3. davisliumd January 19, 2009 at 12:25 am #

    In Gladwell’s book Outliers, he also speaks about the cultural differences in the cockpit which shape communications that can have significant impact. He talks about Power Distance Index (PDI) – the attitudes towards hierarchy and how a culture values and respects authority. Countries with high PDIs, respect authority greatly, which means that the captain may not be challenged if others see a problem or “suggest” the captain take a difference course of action. Countries with the highest at Brazil, South Korea, Morocco, Mexico and the Philippines. Gladwell notes that until Korean airlines understood that until this cultural difference was addressed, they couldn’t improve safety.

    In 2000, they changed their flight operations and required that all pilots train in English and those who wished to continue to fly needed to be fluent in it? Why? By becoming the standard, English provided the Koreans a way out of the hierarchy that they were trapped in which stifled critical communications. They didn’t need to rely on the deference associated when using the Korean language.

    The lowest PDI countries – the United States, Ireland, South Africa, Australia, and New Zealand.

    Perhaps his observations don’t have the same implications in healthcare despite our increasingly culturally diverse workforce since the common language in medicine is English.

  4. ron kirshner February 19, 2009 at 5:23 pm #

    It seems to me that both Sully and Van Zanten ignored suggestions that were given to them by other aircraft professionals. Sully was told to consider landing at another airport and the Van Zanten story is as outlined above. I think that what separates them are simply the outcomes.

    Sully decided to land on the water. If his plane did not have “ditch mode” or his plane did not have another turbine to keep hydrolics active, or first responders were not close by, or the flight attendent did not close the back emergency hatch after it was opened by a passenger, or ….

    I read the Van Zanten story years and years ago, It always troubled me because it downplayed the role of expertise and maybe gives too much “power” to others simply because they are there. I’m not saying this quite right. But i think that there is another explaination for what drove Van Zanten. There are certain types of people that just know when something is not right. These people see the “holes” in the swiss cheese way before others. This is usally the result of years of experience. They just know when something is not right. So here is Van Zanten. He is in an airport with too many planes, certainly too many big planes, fog rolling in, uncertain ATC, and on top of that he has to make an approach to the run way that is not usual. I think that rather than him making some dumb error because he was tired or anxious or arrogant, he made a decision that “I’m just out of here”. I think he felt an unsafe situation was present, didn’t know exactly what it was, but felt that the best way to keep his plane, passengers, and himself safe, was to get out of the situation.

    It was only because of a split second in time or a few feet of clearing space (no different than sully), that he failed. Had he made it, he would have never have been known to be a hero but he would have been nonetheless. No different than Sully.

    So here are my conclusions. First off, whether we like it or not we are judged by our outcomes. Secondly, there is no substitute for expertise. In the name of safety, there is a move a foot to make doctors better rested, better communicators, and more collaborative, I fear that we are losing sight of the overriding importance of expertise. This expertise can only be gained by hours and hours and hours of hard work in our choosen field. In addition, in a time of emergency or life threatening situation “talking green” is critical but only if those doing the talking share some level of expertise.

  5. ron kirshner February 19, 2009 at 7:38 pm #

    By the way, the last word of the reply is “expertise”. Please excuse the spelling, my expertise is surgery and safety, not in knowling how to click spell check prior to posting.

  6. Stuart Benney October 15, 2009 at 5:20 pm #

    I was looking for info of this crash to compare with power imbalance cultures in hospitals for an assignment about interprofessional working in a Radiotherapy department. Brilliant.

  7. iulian February 13, 2014 at 3:00 am #

    hello, i was just reading about the tenerife disaster and came about to this. it is really smart what you are proposing, to have some sort of cockpit resource management paralell to medicine. i am from romania and after doing some research about the plane crash and CRM, i can definately tell you that most doctors in romania are in the dutch pilot paradigm. is there any public official standard regarding some CRM correspondent in medicine and healtcare? thank you

  8. Dak April 9, 2014 at 4:24 pm #

    Ron,

    Captain Sullenberger didn’t ‘choose’ to land on the Hudson vice Teterboro, physics made the choice for him. This is why he responded, after astutely gathering all information, “unable.” Had he attempted the airport, the aircraft would not have made the field, as has been proven by simple analysis of the glide ratio and energy state of the aircraft, and everyone on board, and many on the ground, would very likely have died. ATC didn’t ‘tell’ the crew to divert to Teterboro, they replied to his query about nearby airports, which they did, briefly, consider.

    Captain Sullenberger performed a flawless application of CRM, in the highest-stake and most time-constrained scenario imaginable.
    Additionally, the tower or other ATC position doesn’t ‘tell’ the crew what to do in emergency situations. They offer information and assistance. The captain is in command of the aircraft, period. This is a common area of confusion with the general public.

    Captain Van Zanten could NEVER be considered a hero. Not in a million years. Charging down a runway in to a fog bank in a heavy jet WITHOUT A TAKEOFF CLEARANCE directly resulting in the death of 583 people is the act of a captain who has let his sense of mission override his responsibility to the safety of his passengers and crew. I’ve flown with this type, sadly, and it’s only a good first officer that can prevent such behavior. Incidentally, these characters are often beloved by management (who doesn’t fly with them), because, until something happens, they look great, on paper.

    If Van Zanten HAD managed to clear the Pan Am aircraft, he would be guilty of criminal recklessness, in addition to other violations of aviation regulations for departing without clearance. This situation is exactly why we have control towers in the first place, because the perspective from the cockpit, while on the ground, is too limited, at times. When in ANY doubt, a safe aviator STOPS the aircraft. Van Zanten wasn’t safe, he was bold. So goes the old saying, “There are old aviators, and there are bold aviators, but there are no old, bold aviators.” Van Zanten was one of the last of that dying breed, thankfully, but it’s a damned shame so many innocents had to ride his ego out of this world with him.

    On another note, the ditching switch on Captain Sullenberger’s aircraft was never pressed (this is why the aircraft ultimately sank). This was not a simple oversight by the flight crew, but it was arguably a systemic error in that the switch press was located at the very end of a lengthy checklist that the crew hadn’t completed by splashdown.

    Ordinarily, the subtleties of the aviation world trip up laymen in ways that only amuse us, and no harm is done, but your careless handling of two reputations, in such grave context, cannot stand.

    I strongly recommend the NOVA special referenced, and the numerous reenactments of Captain Sullenberger’s flight, if you’re truly interested. Additionally, I’m happy to answer any questions about aviation safety culture and procedures.

    Dak

Leave a Reply