Error reduction through team leadership: what surgeons can learn from the airline industry.

About 1815 PST on December 28,1978 Flight 173 crashed into a wooded, populated area killing 8 passengers and 2 crewmembers, and seriously injuring 21 passengers and 2 other crewmembers. The National Transportation Safety Board determined that the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crewmembers’ advisories regarding fuel state. This resulted in fuel exhaustion to all engines. Contributing to the accident was the failure of the other two flight crewmembers to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain. The Safety Board believes that this accident exemplifies a recurring problem—a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight. —National Transportation Safety Board (1979)14