The Practiced Art of Airline Safety

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10:15 a.m., eastern daylight time.

The air is cool and quiet, save for the rustle of the drapes and the ripping noise made by Sabra as she opens some suture packs. Cindy is busy setting up her Mayo stand, upon which she has arranged a collection of shiny surgical clamps, two scalpels, some sutures and some silk ties. She has carefully counted the sutures and the instruments, too.

I watch with absent thought as Janet paints the patient's right chest with Betadine solution. Things are going well, we started on time and the first part of the operation has gone well. Soon I will be looking at this young man's heart and freeing his esophageal tumor from his thoracic aorta. This is my usual world, I am at home here.

Suddenly I am overtaken by a series of other images, ones I saw just a week ago. They are sights I saw in fellow columnist Les Abend's world. Since I love aviation and surgery, and because I've developed an interest, some say an obsession, with the application of aviation safety techniques in the surgical environment, those images are now superimposed onto the draped patient before me.

Les had arranged for me to travel with him on a four-day trip. American Airlines had obtained permission from the Federal Aviation Administration for me to sit in the jumpseat and watch the way the pros practice safety. Those four days will be forever tattooed in my visual, aural and emotional memory. For a lifelong airline pilot aspirant, the adventure was so rich, so succulent, that I am speechless when it comes to thanking Les, the FAA, American Airlines and its chief pilot, Mark Hetterman, and its CEO, Gerard Arpey, the man who gave us the green light. In the post-9/11 world, it took a lot to make it happen.

But happen it did. The differences between Les's environment and mine were many and the experience has sobered me about the safety work we have left to do in surgery. From the airline pilot's sign-in to the final after shutdown checklist, aviation has got plans and backup plans that are far more evolved than those we have in the operating room.

Here's what I saw over those four magical days. We started with a sign-in one hour prior to departure. In the operations area Les called up the flight plan, departure, en route and arrival weather and printed it out. The final document was a strip of paper approximately nine feet in length. Les expertly folded the pages into a coherent set of useful chunks of information, then, in a practiced way, tore along pre-perforated lines to separate the sheets into several packets of data.

I can't tell you that I ever fully comprehended all of the items that he printed out, but I do know that there was a lot of information there. Our first flight was from Fort Lauderdale to San Juan, Puerto Rico, a distance of 908 nautical miles. The flight plan included the route, the latitude and longitude of each waypoint, the expected time of waypoint passage, the fuel remaining at each point, the predicted takeoff weight and total fuel on board. That total fuel was calculated to include the predicted fuel burn en route, taxi allowance, reserve and alternate provisions and fuel to hold. Our alternate was Santo Domingo, Dominican Republic. Les took the total fuel on board, subtracted the reserve and alternate amount and divided the rest by 130 lbs of jet-A per minute of flight. He calculated we had another 50 minutes of gas, which he called his "play around" reserve. He seemed satisfied.

That was just three feet of the printed information and Les carefully reviewed the remaining six. There he found notams, winds aloft, a list of American's minimum equipment list (MEL) revisions, a note about the need to establish communications with Havana ATC 10 minutes prior to entering their airspace, a lengthy text description of the prog chart, runway conditions, frequencies for a variety of services (ATIS, FBOs, etc.), deicing conditions (it was hot everywhere), the names of all crewmembers and their nicknames, and the V speeds for each runway. I'm sure there was more that I couldn't decipher.

There was a note about being sure to turn off the center tank fuel pumps when the tank held less than 1,000 lbs of fuel, a lesson learned from the analysis of the TWA 747 that blew up over the Atlantic Ocean en route from New York to Paris. During our four-day trip the 10th anniversary of that accident occurred, reminding all of us that aviation, though safe, can be dangerous.

It was time to board American's elegantly shaped and traditionally painted 757. Les introduced me to Robert Wall, our first officer. We had our first of many lengthy conversations with gate agents; they were all very suspicious of a jumpseater not in uniform and without an ID. I produced a very official looking slip sent to me by American entitled "Admission to Flight Deck." It carried the signatures of the chief pilot and of the principal operating inspector (POI). In a way each of these encounters was reassuring: American is very particular about who sits in their cockpits.

Safety emphasis was everywhere. The airplane had just come from our destination, San Juan, and Les made sure to ask the incoming crew about the flight conditions they had just encountered and the airplane they had just flown. It took only a minute, but it spoke volumes.

Les volunteered to do the walk-around and I had hopes of doing it with him. But a ramp agent quickly pointed out that I didn't have an employee badge and that the Broward County Police would soon be on the scene were I to participate. "They'll rip my badge off me and I'll be out of work," he said. I was disappointed and reassured at the same time.

Back on board, Les gathered the flight attendants around him just outside the cockpit door, introduced me and Robert to everybody and reviewed the procedures for entering the cockpit. I can't tell you what they are, but I can tell you that you can't just knock and get in. Les reviewed what the plan was for an emergency. "If there's a fire, I'll tell you which doors not to use. So if you can't hear everything, but you hear left over wing, don't open that exit. If you see a man in an asbestos suit, try to catch his attention." We all listened with rapt attention.

Once in the cockpit, I settled into one of the two jumpseats. There I watched two pros get ready for some over-water night flying. They reviewed the route, entered it into the Flight Management Computer (FMC), cross-checked each other and set the proposed bug speeds for takeoff. Les briefed Robert as to what to do if we had an emergency on takeoff. Since it was Robert's leg, Les proposed a return to the field that would leave the airport visible out of Robert's side of the cockpit. A small thing to be sure, but quiet evidence of forethought.

Robert and Les remembered the protocol for that center tank pump drill slightly differently. Instantly, Les hauled out the operations manual and showed Robert the exact wording of the plan. I was to see them show each other texts many times over the next few days-usually final takeoff weights, V speeds and flap settings. Rather than being reluctant to consult the ops manual, both pilots seemed eager to precisely remind themselves of the exact procedure. American Airlines doesn't raise cowboys, they train pilots. We do so little of this in medicine, I found myself thinking. Push Back. 187 souls were now entrusted to two men. Each pilot looked out his side window, extending a thumb up to signify that they saw no obstruction to aircraft movement. The air crew alert and reporting system (ACARS), via a small little printer right in front of me, now spit out the "Load Closeout" comprised of a final passenger count, takeoff weight, fuel on board weight and the zero fuel weight, among other things.

Robert read the checklist. Once again the V speeds, stabilator setting and power settings were rehearsed. Les said, "Starting number L." He reached up, set the left engine to "GND" and, when acceptable N2 and N3 figures were met and the EGT fell below 100, Robert flipped the fuel control to run. With both running we were cleared to taxi. Our four-day trip was starting on time. "Flaps 15," said Les. Robert positioned the flap lever, watched the indicator and when he was satisfied that they were indeed not just set, but actually deployed, said, "Flaps 15 and checked." After that, he put the flight controls through their travels and we all watched on the screen as the indicators moved appropriately. We were underway.

American has a simple mechanical checklist bolted to the left of the copilot's flight instruments. It is straightforward, easy to see, illuminated. As we taxied out, we worked our way through the list, which contained about 10 items. Each item is familiar to any pilot. The only difference was our takeoff weight: 217,000 pounds.

The whole feeling of this flight deserves its own detailed description, but the safety aspects are the focus of this piece. The takeoff, call outs, and gear and flap retraction all occurred quickly and without hesitation. Robert and Les had done this before and they had, this month, done it together before. The atmosphere was a combination of alertness and banality.

Out of 10,000 feet, Les signaled the flight attendants by cycling the seat belt sign switch; the ACARS extruded a strip of paper like a child sticking out his tongue. Les tore it off and handed a copy to Robert. It had our out and off times, a recalculated time of waypoint passage and recalculated fuel remaining at each waypoint. Both pilots put a copy on their yokes and on each and every flight I would watch them each religiously write down the actual time of passage and fuel remaining. Any discrepancy would have triggered action long before a crisis became evident. Over the next four days I would watch Les and Robert nail bug speeds, fly conservatively around any suspicious splotches on radar, check frequently with ATC about ride reports, weather and short cuts, honor each and every checklist and procedure, kid each other in innocent but familiar ways, and land on speed and on target over and over. I came to appreciate the feeling of family among American's people. The airline lost two crews on September 11th and their anti-terrorism procedures are impressive. I'd love to tell you about them, but the FAA, Department of Homeland Security, the airline and my mother would disapprove. Suffice it to say that every anti-terrorist device and procedure that I had ever read about or heard about, I saw on the trips I took. I was deeply impressed by the airline's commitment to safety.

Back in the operating room, while closing the chest, I'm thinking of everything I saw on my adventure on American. From visiting Les's world, I see how far we've got to go in surgery in order to reach the level of precision, the culture of communication, and the commitment to safety that we all take for granted when boarding an airliner. Thinking back to those four magical days, I can't wipe the grin off my face. Good thing I'm wearing a mask.