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Disaster averted in NYC

January 16, 2009
by kate
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Those of us working and living in New York City had a huge scare yesterday. In the late afternoon, breaking news hit that a commercial plane had crashed into the Hudson River. Immediately, most of us feared the worst. Even if the impact itself didn’t cause serious damage, the waters were frigid, meaning it would be impossible for anyone to swim to safety (temperatures yesterday were at the coldest they had been all season — until today).

As the media learned and related more information, and reports started to surface that all of the 155 passengers and crew members were believed to be safe, a huge wave of relief swept over the city. But it was more than relief; it was shock — particularly as the details become known.

· First, the accident was caused by geese that had flown into not one, but both of the engines. As a result, the pilot, Chesley “Sully” Sullenberger, had to float the plane into the river.

· Second, the reason that the temperature of the water — a chilling 36 degrees — wasn’t a huge factor (experts said that hypothermia can hit within five to eight minutes at that temperature) was that the response was so rapid from nearby commuter ferries as well as the coast guard. Passengers were able to stand on the wing of the plane as they were ushered right onto rescue boats (see the amazing photo below). Only a few had to wade in the water, and not for very long.

My take from all of this is that there were two key factors that saved the passengers and crew — leadership by the pilot, who was able to remain calm and make a landing that is being called the “Miracle on the Hudson,” and preparedness on the part of the ferry operators and local authorities.

The November, 2008 issue of HCI features an article I wrote on disaster preparedness (Weathering the Storm); in that piece, the same two themes kept emerging: leadership and preparedness. I realize that in light of the economic situation, disaster preparedness/recovery may not be on top of every healthcare executive’s priority list, but yesterday’s incident serves as another reminder that you never know what might happen. A hospital could get hit by a storm, a blackout, a flood, an earthquake, or even a terrorist attack (scary, but a reality), and executives need to do their best to ensure that if disaster strikes, their facility is ready.

Take a lesson from Lynn Witherspoon, vice president and CIO at Ochsner Health System in New Orleans (which, after surviving Hurricane Katrina, was much better prepared when Hurricane Gustav hit this past fall).

“We had a real-life experience that taught us the value of getting our disaster plan in place.”

Be prepared, because you never know what tomorrow could bring.

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Comments

Kate,

I'm with Gwen. It's a great post because there are important learning points for readers, and, of course, because there's a human story and photo. I'd like to extend the learning for the HCIT context.

In the 2002 timeframe, it was clear to many people working in patient safety that the approaches were often missing the mark.  Even when the focus was elevated to consider patient safety a proper subset of Quality, there was still something critical missing.

A recurring good pattern in healthcare is to learn lessons from other industries.  Exemplary sources of these lessons have come from the Quality focus, Six Sigma, Agile with Lean, Throughput and other methodologic orientations that have proven very powerful in other industries.  Another methodologic paradigm, especially relevant to Disasters, like this Miracle on the Hudson, is taking a High Reliability Organizational (HRO) orientation.  Here's a summary (and an attached file with a complete, annotated presentation on the topic of HRO in healthcare.)




/Media/BlogReplies/2005 Bormel - From Crisis to Confidence, Creating High Reliability in Healthcare.pdf

The application to the Disaster averted in NYC are clear.

1.  The pilot had practiced and practiced recently drills related to what to do in response to single and dual engine failure.  In the attached "From Crisis to Confidence," there's another airline incident with the opposite outcome (less than 10 survivors).  As a result, before pilots begin their landing into Cali, Columbia, they review what they'll do in the event of engine failure.  They're Preoccupied with Failure, and therefore better prepared.  In the case of American Airlines flight 965 in that story, there were less than 11 seconds between crisis and crash.  That calls for planning and simulation.

2.  We all know that NTSB will elaborate all of the contributing factors to this incident.  Most talented executive I know insist on doing RCA and FMEA.  And, oh yeah, TJC insists on it as well in our world.  That's reluctance and sensitivity.

3-5.  In the interest of brevity, the remaining points get at the issue of the ability to mobilize a rapid and effective response.  Life jackets, the rapid response of the rescue vehicles, the immediate hold of aircraft at LGA until probable cause was determined, etc, are all examples.

I'll end this with a very, very concrete suggestion for HCIT, as an example:  Backup Verification Services.  How many CIO readers have had their backup media from their recent backups tested, by a third-party?  At the risk of being insensitive, I know for a fact that the number is not 100%.  This is a great example of a behavior of a HRO and something that's fast and inexpensive to get accomplished.

I've always ended my HRO presentation with a joke, so I'll do that again here.  You'll need to open the attached PDF and open to the last slide.  I'm trained as a scientist. I'm also committed as a parent, perhaps less trained for that role.  So, I've randomized my kids, treading one safely and the other as a control.  Follow up with me in 20 years and we'll see if it makes a difference!  (Note: my daughter is wearing a safety helmet; they're both sitting on the same arguably unsafe ledge.)

Gwen, thanks for your kind words!

It goes without saying that above all, we're all just so relieved that everyone is okay. I'm still amazed by the whole turn of events. And I think that one of the silver linings is that as someone who works in NYC, I feel like this city is prepared to handle anything.

Joe, I've done some reading on the subject and haven't found anything about Captain Sully's checklists. But it's a very interesting point.
Leaders are expected to be able to anticipate and manage the unexpected, which by definition sounds impossible, yet it is done in hospitals every day. Amazing.

Seneca said that even in times of good fortune, a wise man should prepare for the inevitable disasters of life through periods of self-inflicted privation (limited food, living out of doors). Training for hazardous jobs, such as pilot, similarly revolves around how to react when things go wrong. I guess our hero was paying attention.

Kate,

Terrific post! In my mind the mark of a great journalist is someone who can take timely events and make the lessons learned relevant to each and every one of us, no matter who we are, what we do for a living, or where we are in our lives. Congrats!

Gwen

I am familiar with Dr Provonost's work, and Dr Atul Gawande's coverage and contextualization of it. So, I concur with your "Go Peter Provoonost!"

Can you expand on the checklist that Captain Sully, our latest, new national hero used? Was it etched in his brain from thirty plus years of piloting, or was it etched in paper or the control systems of his plane? The news accounts I've read have been silent on checklists.

He used a checklist when the engines failed! Go Peter Provonost!

kate

Kate Huvane, Associate Editor of...