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Letters to the Editor: Letter to the Editor

The Limitations of Crisis Checklists

Borshoff, David MBBS, FANZCA

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doi: 10.1213/ANE.0000000000000183
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To the Editor

In citing the well-known and very successful landing of flight 1549 on the Hudson River, Goldhaber-Fiebert and Howard1 raise some important issues regarding the use of cognitive aids and checklists in time-sensitive crisis scenarios. An alternative perspective, however, is that the “dual engine restart” checklist proved a distraction (the aircraft was too low and the engines irreparably damaged), and the reason for the successful outcome was the pilot’s training, experience, and safety awareness—an example no less valuable to anesthesiologists. The success of the Hudson River landing was more consistent with Klein’s recognition-primed decision-making model mentioned later in the article; a process that “…allows difficult decisions in less than ideal circumstances.”2 In this instance, the Captain had very quickly assessed altitude, engine performance, airspeed, and landing opportunities—perhaps the only checklist benefit was to prevent or shorten the “startle” effect.3

Emergency manuals or cognitive aids can help improve performance4 but concerns remain. An incorrect diagnosis can lead to the wrong checklist being used, and a disproportionate sense of urgency can result in fixation error. It is also reasonable to predict that specific checklists will not be a perfect fit for every clinical context and may actually distract from task prioritizing. Interestingly on flight 1549, the directive to seal doors and hatches for water landings was on a different checklist and not completed.a

In aviation, the mantra “aviate, navigate, communicate” in response to sudden, adverse changes in conditions allows the pilot to direct attention to the most important issues first. In my institution, we have adapted this mantra to “call (for help), communicate (the problem), and delegate (tasks),” allowing the anesthesiologist to maintain focus on the patient.

Emergency manuals may prove their usefulness in anesthesia over time, but as Captain Sullenberger demonstrated, good training, clinical experience, and commitment to safety remain the core components of crisis management.

Conflicts of Interest: David Borshoff is the author of The Anesthetic Crisis Manual, North American Edition, Geoffrey Lighthall, ed. Published by Leeuwin Press, Australia.

David Borshoff, MBBS, FANZCA

Department of Anesthesia and Pain Medicine

Royal Perth Hospital

Perth, Australia


a Air and Space SmithsonianInterview: Sully’s Tale. Available at: Accessed November 11, 2013.
Cited Here


1. Goldhaber-Fiebert SN, Howard SK. Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events? Anesth Analg. 2013;117:1149–61
2. Orasanu J, Connolly TKlein GA, Orasanu J, Calderwood R, Zsambok CE. The reinvention of decision making. Decision Making in Action: Models and Methods. 1993 Norwood, NJ Ablex Publishing Co:3–20
3. Richard De Crespigny. Chapter 14.. Boom!..BOOM! QF 32: The Captains Extraordinary Account of How One of The Worlds Worst Air Disasters Was Averted. 2012 Sydney, Australia: Pan Macmillan Australia;:155–65
4. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246–53
© 2014 International Anesthesia Research Society