The Checklist Manifesto_ How to Get Things Right - Atul Gawande [71]
“That was so long ago,” Sullenberger said, “and those gliders are so different from a modern jet airliner. I think the transfer of experience was not large.”
It was as if we simply could not process the full reality of what had been required to save the people on that plane.
The aircraft was a European-built Airbus A320 with two jet engines, one on each wing. The plane took off at 3:25 p.m. on a cold but clear afternoon, headed for Charlotte, North Carolina, with First Officer Jeffrey Skiles at the controls and Sullenberger serving as the pilot not flying. The first thing to note is that the two had never flown together before that trip. Both were tremendously experienced. Skiles had nearly as many flight hours as Sullenberger and had been a longtime Boeing 737 captain until downsizing had forced him into the right-hand seat and retraining to fly A320s. This much experience may sound like a good thing, but it isn’t necessarily. Imagine two experienced but unacquainted lawyers meeting to handle your case on your opening day in court. Or imagine two top basketball coaches who are complete strangers stepping onto the parquet to lead a team in a championship game. Things could go fine, but it is more likely that they will go badly.
Before the pilots started the plane’s engines at the gate, however, they adhered to a strict discipline—the kind most other professions avoid. They ran through their checklists. They made sure they’d introduced themselves to each other and the cabin crew. They did a short briefing, discussing the plan for the flight, potential concerns, and how they’d handle troubles if they ran into them. And by adhering to this discipline—by taking just those few short minutes—they not only made sure the plane was fit to travel but also transformed themselves from individuals into a team, one systematically prepared to handle what ever came their way.
I don’t think we recognize how easy it would have been for Sullenberger and Skiles to have blown off those preparations, to have cut corners that day. The crew had more than 150 total years of flight experience—150 years of running their checklists over and over and over, practicing them in simulators, studying the annual updates. The routine can seem pointless most of the time. Not once had any of them been in an airplane accident. They fully expected to complete their careers without experiencing one, either. They considered the odds of anything going wrong extremely low, far lower than we do in medicine or investment or legal practice or other fields. But they ran through their checks anyway.
It need not have been this way. As recently as the 1970s, some airline pilots remained notoriously bluff about their preparations, however carefully designed. “I’ve never had a problem,” they would say. Or “Let’s get going. Everything’s fine.” Or “I’m the captain. This is my ship. And you’re wasting my time.” Consider, for example, the infamous 1977 Tenerife disaster. It was the deadliest accident in aviation history. Two Boeing 747 airliners collided at high speed in fog on a Canary Islands runway, killing 583 people on board. The captain on one of the planes, a KLM flight, had misunderstood air traffic control instructions conveying that he was not cleared for takeoff on the runway—and disregarded the second officer, who recognized that the instructions were unclear. There was in fact a Pan American flight taking off in the opposite direction on the same runway.
“Is he not cleared, that Pan American?” the second officer said to the captain.
“Oh yes,” the captain insisted, and continued onto the runway.
The captain was wrong. The second officer sensed it. But they were not prepared for this moment. They had not taken the steps to make themselves a team. As a result, the second officer never believed he had the permission, let alone the duty, to halt the captain