On the morning of 9/11, I was preparing to leave Virginia for a Naval training event with Strike Fighter Squadron (VFA) 131. Just before 9 a.m., my wife called from work and told me to turn on the TV. I was in utter shock as I witnessed our nation under attack, on live television. I told my wife I needed to report to my squadron immediately.   

Though I didn’t know it at the time, what happened that day would not only disrupt my immediate plans, but also demonstrate the tremendous reliability and resiliency of our Naval Air Forces. I later came to understand that what allowed us to pivot and respond so well to crisis was acting like a high reliability organization (HRO)—using the same principles that keep healthcare systems performing at peak efficiency, even amid catastrophe. 

The following HRO principles allow us to respond effectively when faced with a threat—be it a terrorist attack or global pandemic.  

  • Preoccupation with failure, or thinking through all possible scenarios where harm could occur and noticing small signs that could signal trouble 

  • Standardization, or the creation of consistent processes that allow individuals and groups to act fast  

  • Consistent communication to ensure everyone involved understands the objectives and plan in place 

  • Deference to expertise, or placing knowledge above rank and encouraging all people to speak up when they notice a problem 

Those with an HRO Mindset Think Ahead to Minimize Damage 

Within minutes of when I arrived, the base, along with every U.S. military installation across the globe, went into lockdown.  

When faced with a threat, the U.S. military follows levels of force protection based on the threat’s severity. These preventative measures are drawn from a preoccupation with failure, a key HRO principle for getting ahead of harm. Force protection conditions (FPCONs) can be region-specific and become more robust as the threat increases. At the time of the terrorist attack, the understanding of the threat was unclear, but the response to increase our FPCON measures was immediate and effective. The same applies to the decision to ground all commercial aircraft flights in the continental U.S., which was accomplished in a matter of hours. 

Preoccupation with failure is also apparent in healthcare when leaders identify a system problem in one unit and immediately question where else this problem may exist in their organization. Taking widespread action fixes an issue, such as a process, supply, or equipment failure, before it can impact patient safety. 

Standardization Leads to Fast Action and Reliable Results 

When I arrived at my squadron, my commanding officer, who was one of four pilots scheduled to fly the last aircraft to the carrier USS John F. Kennedy, was already coordinating with local Naval leadership on what to do. The aircraft were the only ones on the base configured for carrier operations and ready to deploy wherever they were needed. The decision was made to load them with the few live air-to-air missiles on the base and fly instead to USS George Washington (CVN 73), an aircraft carrier that was already conducting training operations off the coast of Virginia. The ship would then sail north to provide additional air defense along the east coast, with our aircraft flying combat patrols to intercept any potential aerial threats.   

Amazingly, these decisions were made in less than an hour, actions were delegated to responsible parties across multiple organizations, and coordination expanded to all forces conducting air defense along the east coast. Moving so quickly would not be possible without another HRO principle, standardization

Because all of VFA-131’s maintenance personnel were already aboard John F. Kennedy, and there was no expectation that ordnance would need to be loaded, maintenance personnel from another squadron were brought in on short notice to load our aircraft with live weapons. The process for loading ordnance on the jets in our squadron is the same for all 35 squadrons in the Navy, so it was just an issue of getting a team to complete the task. This standardization reflects similar healthcare best practices, such as setting guidelines for bedside shift reports across nursing units to ensure a safe patient experience.   

Consistent Communication Fuels Safer Operations 

As the maintenance personnel loaded our aircraft with weapons, the pilots briefed for the flight to USS George Washington. Every military flight, whether routine training or combat, is thoroughly briefed to ensure the participants fully understand the plan and objectives and to identify and address any threats to safety or mission success. It’s just one more example of a preoccupation with failure. While the brief is conducted by the flight lead, everyone is expected to participate and can address any concerns they may have related to safety or the mission (this can include personal challenges like a lack of proficiency). Following every flight, there is also a thorough debrief focused on a review of training and/or mission objectives and opportunities for improvement on the next flight. The first question in the debrief is “Were there any safety issues?” to ensure that everyone understands the high-risk nature of the work and the prioritization of safety.  

The Brief-Execute-Debrief process, also used in some areas of healthcare, is an excellent method to ensure the entire team is aligned and prepared for any complex task and to learn and improve when the task is repeated. 

The focus of our brief was on the non-standard aspects of our flight, including the transition from land-based to sea-based operations, carrying live weapons, and the rules of engagement that we faced in the event of being required to intercept a hijacked commercial airliner. 

Following the brief, we launched and headed to USS George Washington, which was over 800 miles away from our planned destination. Our flight was uneventful, and though our new temporary home was much different from our original destination—USS John F. Kennedy being a conventional, fossil fuel-burning aircraft carrier commissioned in 1967 and USS George Washington a nuclear-powered aircraft carrier commissioned in 1990—the actual landing area, visual landing aids and communications equipment are very similar across all 11 aircraft carriers.   

This level of uniformity in carrier design, combined with highly standardized communication between pilots and landing signal officers (LSOs), meant that the only information needed to shift carriers was an estimated location of the ship (within roughly 50 miles), the frequency for their TACAN (a beacon to locate the ship), the scheduled time to land, and the radio frequency to communicate with the LSOs. 

Such standardization mirrors what is needed in many healthcare scenarios, like when an on-call interventional radiologist that the team has never worked with is scheduled to cover a weekend while the regular radiologist is on vacation. Regular practices must be put in place to ensure no interruption in care occurs. 

Trust in Expertise Provides Physical and Psychological Security 

After landing aboard the carrier and securing the aircraft, we debriefed our flight, including a debrief from the LSOs who evaluated our landing performance. Landing aboard an aircraft carrier can be challenging, and even catastrophic, with significant deviations in proper angle of attack/approach speed, proper glide slope (being high or low on the approach), and proper alignment with the landing area (not being left or right of centerline). LSOs back up pilots as they land on a carrier by alerting them to deviations (often before the pilot even sees the deviation). They then evaluate and grade each landing in order to identify and correct any unsafe trends in a pilot’s landing performance. This third example of the military’s preoccupation with failure is akin to using real-time performance metrics in healthcare (such as CAUTI or CLABSI bundle compliance) to identify trends and take action before an infection occurs. 

The interaction between LSOs and pilots also highlights another high reliability principle that the military often relies on: deference to expertise. LSOs are pilots, but they are relatively junior ranking in the military hierarchy. All aviators (regardless of their rank) know to immediately respond to LSO inputs and commands because their lives depend on it. It’s very common in Naval aviation for lower-ranking members of the team, who have expertise in their job functions, to immediately provide input to (or even stop) an activity on the flight deck if there is any concern for safety or mission success. This model sets a precedent for healthcare organizations, where the real or perceived presence or influence of a team leader can create an unsafe situation in which staff are too intimidated or afraid to speak up. 

Following the LSO debrief, we prepared to conduct combat air patrol flights. Eventually, in the early afternoon, we learned that any further air threats to our country were unlikely. The entire nation was coming to an understanding of what had happened. The carrier’s strike group admiral informed us that we were continuing to sail north, with the plan to be off the coast of Manhattan the following morning to show support to the people of New York.   

The next morning, as we looked from the flight deck of the aircraft carrier onto the city, it was chilling to see the dust and smoke still billowing upward from where the towers previously stood. Images like that will be forever etched in our collective memory. However, just as the power of that day took an immense emotional toll on the country, it also serves as a powerful example of how high reliability principles can help any organization and industry during routine, emergent, and crisis situations.