The Checklist Manifesto_ How to Get Things Right - Atul Gawande [72]
The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).
Here are the details of one of the sharpest checklists I’ve seen, a checklist for engine failure during flight in a single-engine Cessna airplane—the US Airways situation, only with a solo pi -lot. It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup fuel pump switch ON. But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget this most basic task. FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival.
About ninety seconds after takeoff, US Airways Flight 1549 was climbing up through three thousand feet when it crossed the path of the geese. The plane came upon the geese so suddenly Sullenberger’s immediate reaction was to duck. The sound of the birds hitting the windshield and the engines was loud enough to be heard on the cockpit voice recorder. As news reports later pointed out, planes have hit hundreds of thousands of birds without incident. But dual bird strikes are rare. And, in any case, jet engines are made to handle most birds, more or less liquefying them. Canadian geese, however, are larger than most birds, often ten pounds and up, and no engine can handle them. Jet engines are designed instead to shut down after ingesting one, without exploding or sending metal shrapnel into the wings or the passengers on board. That’s precisely what the A320’s engines did when they were hit with the rarest of rare situations—at least three geese in the two engines. They immediately lost power.
Once that happened, Sullenberger made two key decisions: first, to take over flying the airplane from his copilot, Skiles, and, second, to land in the Hudson. Both seemed clear choices at the time and were made almost instinctively. Within a minute it became apparent that the plane had too little speed to make it to La Guardia or to the runway in Teterboro, New Jersey, offered by air traffic control. As for taking over the piloting, both he and Skiles had decades of flight experience, but Sullenberger had logged far more hours flying the A320. All the key landmarks to avoid hitting—Manhattan’s skyscrapers, the George Washington Bridge—were out his left-side window. And Skiles had also just completed A320 emergency training and was more recently familiar with the checklists they would need.
“My aircraft,” Sullenberger said, using the standard language as he put his hands on the controls.
“Your aircraft,” Skiles replied. There was no argument about what to do next, not even a discussion. And there was no need for one. The pilots’ preparations had made them a team. Sullenberger would look for the nearest, safest possible landing site. Skiles would go to the engine failure checklists and see if he could relight the engines. But for the computerized voice of the ground proximity warning system saying “Pull up. Pull up. Pull up. Pull up,” the cockpit was virtually silent as each pilot concentrated on his tasks and observed the other for cues that kept them coordinated.
Both men played crucial roles here. We treat copilots as if they are superfluous—backups who