
On January 15, 2009, U.S. Airways Flight 1549 departed from LaGuardia International Airport.
In New York City, with non-stop service to Charlotte, North Carolina. At 15:25:39 hours, Flight 1549 stowed its landing gear and began its ascent to cruising altitude. Less than two minutes after stowing its landing gear, Flight 1549 struck birds less than 5,000 feet off New York City.
We all know what happens next; the brave work of Captain Sullenberger and First Officer Skiles successfully landed the commercial aircraft on the frigid Hudson River, saving the lives of all 155 souls on board. A day that will live in aviation heroism for eternity. However, what I find most interesting about this event is not the physical act of landing the aircraft on the Hudson River but rather the use of practice, repetition, reference material, and cognitive offloading.
15:27:10- First Officer Skiles: “BIRDS!”
15:27:11- Captain Sullenberger: “…woah. My Aircraft.”
15:27:23-First Officer Skiles: “Your aircraft.”
15:27:28 Captain Sullenberger: “Get the QRH (quick reference handbook). Loss of thrust on both engines.”

Eighteen seconds after what could have been one of the greatest aviation disasters in history, the flight recorder transcript revealed that Captain Sullenberger was reaching for a reference handbook… a checklist.
In 1935, the Boeing B-17 prototype crashed during a test flight, killing both pilots. After the fact, the preflight/departure checklist was developed for all subsequent test flights within the Boeing company, resulting in considerably fewer sentinel events. In the following years, other airline industries, including the United States military and, ultimately, NASA in the 1950s, began incorporating checklists into their daily operation. Before long, these checklists became standard practice in the aviation industry. The reality of this transition was simple and apparent- aviators knew how to do the job. Still, they recognized there was so much content to learn and remember it only made sense to utilize a tool to help them offload and do it better.
We often hear of EMS, and more generally healthcare as a whole, being compared to the aviation industry regarding safety culture and utilizing checklists. While I believe there is a lot of similarity and crossover, I think the core differs slightly. In aviation, pilots use checklists as a procedural “to-do” and “how-to” guide. It is stepwise and methodical; it outlines each step of the process and how to do it. In acute care medicine, checklists are utilized to confirm that you actually did what you think you did before a pivotal point in a procedure.
For example, a pivotal point in an RSI is right before the induction agent or paralytic is administered. This is an excellent stop point to ensure that you did everything you think you did leading up to this point. You will be surprised by how often someone reads the checklist, and something as simple as a syringe to inflate the ETT or tube holder has not been set up yet.

In Dr. Atul Gawande’s book The Checklist Manifesto, Dr. Gawande asserted that a checklist may constitute anything that guides a situation to promote patient and procedural safety and success.
There was once, and perhaps still is, a stigma that using reference tools implies a lack of implicit knowledge. In simulation, we sometimes hear, “What would you do in ‘real life’ if you didn’t have your phone to look it up?” I think it’s time someone said, “Why wouldn’t I have my phone?!” In 2024, the amount of available knowledge on the internet will increase by 0.4 zettabytes (for those who are not computer nerds like me, that’s one trillion gigabytes) every day! Everyone is more connected than ever before. Knowledge is easier to access than ever before. Is it an excuse not to have implicit knowledge such as life-saving resuscitative pediatric dosing or medical mathematics? Of course not! But it is a tool that should be incorporated into our resuscitation model! If you were resuscitating my child, wife, or mother, I would want you to use every resource available to you in real time. I believe it is less important to memorize the answer and more important to teach ourselves, colleagues, and students how to effectively cognitive offload and find the answer when minutes matter.
Without a checklist on January 15, 2009, the 155 individuals onboard U.S. Airways Flight 1549 may have lost their lives on the Hudson River. If you are not using a checklist for critical procedures, you have to wonder, what could you forget?
References:
Gawande, Atul. The Checklist Manifesto. Profile Books Ltd, 2011.
“US Airways 1549 CVR Transcript.” Cockpit Voice Recorder Database, tailstrike.com/database/15-january-2009-us-airways-1549/. Accessed 28 Nov. 2024.