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The Day the Music Died

“I can’t remember if I cried
When I read about his widowed bride,
But something touched me deep inside
The day the music died.”

These lyrics from Don McLean’s epic, “American Pie”, commemorate a plane crash on the night of February 3, 1959 that killed legendary singers Buddy Holly, J.P. Richardson (The “Big Bopper”), and Richard Valenzuela (Ritchie Valens) along with pilot Roger Peterson.    Holly’s “widowed bride”, Maria Elena, was 6 months pregnant at the time of the crash and her miscarriage several days afterward would add a fifth victim to the tragedy.   The accident indeed “touched many people deep inside” and even today is considered the “first and greatest tragedy rock and roll has ever suffered”.  Holly is viewed by modern music critics as “the single most influential creative force in early rock and roll” and Rolling Stone Magazine ranks him 13th on its list of the “Fifty Greatest Artists of All Time”.  Holly would become the first artist inducted into the Rock and Roll Hall of Fame in Cleveland, Ohio.  The events of that night are a classic example of failure of the high reliability mindset leading to a predictable tragedy.   So as fellow students of the high reliability mindset – and with a background of previous blog posts on error producing conditions – let’s dissect this accident and see what we learn and can apply to patient safety.

 

But February made me shiver
With every paper I’d deliver.
Bad news on the doorstep;
I couldn’t take one more step.

 

Holly and his band, “The Crickets”, were on a “Winter Dance Party” tour that covered twenty-four Midwestern cities in three weeks.  It turned out to be “bad news” for the guys, who had to endure long overnight travel in a bus plagued with a faulty heating system and, with temperatures dropping to −25 °F, “February made everyone shiver”. The bus had a nasty habit of breaking down several times between stops. It got so bad that drummer Carl Brunch was hospitalized for frostbite on his feet, he “couldn’t take one more step” and missed the rest of the tour (and the plane wreck).  Holly was fed up with the creaky old bus and decided to charter a plane to take them from Mason City, Iowa to Fargo, North Dakota for their next gig.  The Big Bopper and Ritchie Valens were on the plane because of two strange twists of fate.  Band mate Waylon Jennings, who would go on to become a famous country music star, was scheduled to fly but gave his seat up to the Big Bopper, who was suffering from the flu and didn’t want to ride the cold bus and guitarist Tommy Allsup flipped a coin with Ritchie Valens for the last seat – Valens won.  All this had prompted Buddy to jokingly tell Jennings, “I hope your ol’ bus freezes up again!” Jennings shot back, “Well, I hope your ol’ plane crashes!”  It was a statement that would haunt Jennings until his death more than four decades later.

For a fee of $36 a passenger, 21-year old pilot Roger Peterson agreed to fly the band.  In the dark at 1 AM, Peterson taxied down Runway 17 and took off – the flight lasted four minutes. They flew into the dark night and directly into a blizzard; the pilot lost visual references to the ground, became disoriented, and flew down instead of up. The plane plowed into a cornfield at over 170 mph instantly killing all four people on board. Their bodies were thrown from the wreckage and remained there for ten hours as snowdrifts formed over them.

Playing “where’s Waldo” let’s find all the error producing conditions that occurred.  The first and also the most common EPC is fatigue; the pilot had already flown a 17-hour workday, but agreed to fly the trip anyway.  We have already seen that fatigue incrementally increases the risk of error and clearly contributed to this crash.  Modern pilots are required to have 12 hours off duty and fly only 8 hours a day.  The next is lack of experience – the pilot was a low time aviator having accumulated only 700 flight hours (minimal flight time for a pilot to even be considered to start training for commercial carriers is now 1500 hours).  He was also not experienced or trained to fly in instrument conditions of a dark night and cloudy conditions.  As a matter of fact Peters had failed an instrument flight check nine months prior to the accident. (This is all very similar to the JFK junior accident 10 years ago.)  The next EPC is unfamiliar circumstances.  The limited instrument flight training he had   was with different instruments that were on the plane he was flying.  When confronted with an unfamiliar situation of the cloudy, dark night he had unfamiliar instruments that were in fact exactly the opposite of what he was used to – the reason he flew the plane down into the ground instead of up into the sky.  Another EPC is the most common in the Joint Commission data base root causes of patient errors – inadequate communication.  Peterson had checked the weather but it was never communicated to him by the aviation weather briefer that there were two weather advisories that warned of an incoming blizzard with obscured vision and low cloud deck.   This lack of communication of critical information, which might have dissuaded Peterson from making the flight, led to a bad decision on his part – to take off into the overcast night and enter the blizzard conditions.

Did we find the major root causes of this accident?  The Civil Aeronautics Board (forerunner of the FAA and NTSB) determined that “the probable causes of this accident were the pilot’s unwise decision to embark on a flight which would necessitate flying solely by instruments when he was not properly certificated or qualified to do so. Contributing factors were serious deficiencies in adequacy and communication of the weather briefing, and the pilot’s fatigue as well as unfamiliarity with the instrument which determined the pitch angle of the aircraft.”  As we have talked about before – these lessons apply in healthcare and patient safety as well as everyday life.  We can predict circumstances when bad outcomes are more likely to occur and it is always when known error producing conditions exist.  Care of complex patients requires that we be extra vigilant when faced with any of these common sets of circumstances such an unusual illness or one that we have not treated recently.  Doing any procedure that you have not done recently and repeatedly requires a mental “pre-brief” to be sure your have the equipment you need and understand how all the instruments work that you are used to using.  As an extra caution, be sure to run through the steps and order of all the tasks your mind before you begin – pilots call this “hangar flying” surgeons can consider it “OR lounge operating”.  By being on guard and anticipating times when complications are more likely, they can likely be avoided and nobody will need to be lamenting, “the day the music died”.

 

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Posted in communication, Error Producing Conditions, Human Factors, Patient Safety.

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3 Responses

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  1. skulljockey says

    Perhaps I can add to the narrative and extrapolate a couple of more EPCs and matrix them to the health care sector. I wonder whether the decision to fly that night, given the inexperience using instruments and perhaps lack of understanding of the impact of fatigue on performance would suggest “faulty risk perception”.
    Although we all understand the the concept of time pressure and how that can hinder our efforts to complete a task correctly sometimes adopting the time pressures of others unknowingly. In this case, the pilot inherits the urgency of his clients to get to the destination. An example of this may be the hurried manner needed when others want to acess a health care resource such as an operating theater.

  2. kenstahl says

    Yes indeed the entire event was a failure to perceive the huge risk of the flight each individual error producing condition was a subpart of this overall fault. Thanks again for weighing in with your insightful comment.

  3. Tony Kern says

    I’d like to tag on to skulljockey’s “faulty risk perception” concept, and link it to the abysmal EMS safety record of the last decade. Selection of a mode of transportation – for ourselves, our patients, and passengers – is one of the most critical risk decisions we make every day. In many of the EMS helicopter crashes, some patients could have, and perhaps should have, been transported by ground ambulance. The team decision making between the medical personnel, first responders, and pilots are as critical now as they were the day the music died. Nice blog Ken.



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