Surgery borrowed the checklist from aviation and stopped there. Three more lessons from the flight line, on distraction, automation, and fixation, are still waiting to be picked up.

On September 11, 1974, Eastern Air Lines Flight 212 descended toward Charlotte in light fog. The cockpit voice recorder captured the crew talking about politics and used cars while the DC-9 sank below its assigned altitude. The airplane hit terrain short of the runway and 72 of the 82 people aboard died. The FAA answered in 1981 with what pilots call the sterile cockpit rule: below 10,000 feet, no conversation and no activity that is not essential to flying the airplane. I learned that rule during my four years as an Air Force flight surgeon, before I finished surgical training, and I have spent the nineteen years since, as a pediatric surgeon, wondering why the operating room never adopted it.

The operating room has a sterile field but not a sterile cockpit.

Every operation has its own version of flight below 10,000 feet. Induction and emergence of anesthesia. The time-out. The critical dissection, when the structures that matter most are closest to the instruments. The counts at the end of the case. These are the phases when a wandering conversation costs the most, and they are exactly the moments when the room is often at its loudest. The music stays up. The door swings open for a question about the next case. A phone rings at the circulator’s desk. A device rep offers commentary. None of it is malicious, and most days none of it matters.

I cannot point to a case of my own that went wrong because of the noise. Neither could the crew of Flight 212, on every approach before the last one. That is what makes this hazard hard to respect. The risk for a rare event is the easiest one to stop seeing, and the sterile cockpit rule exists because aviation quit waiting for each crew to learn that firsthand.

I do not want a silent operating room, and the evidence does not ask for one. Studies have found that music the surgeon chooses improves speed and accuracy at the table. Aviation did not ban conversation from the cockpit either. It named the critical phases and protected them. That is all I am asking of the operating room. A crew that talks easily is a crew that speaks up easily, and I wrote in these pages before about why that matters. When the anesthesiologist is inducing a child, when the count is open, when I am dissecting near something that does not forgive, the room should sound different, and everyone in it should know why.

The autopilot still has to be watched

In July 2013, Asiana Airlines Flight 214 struck the seawall short of the runway at San Francisco on a clear day. Three passengers died. The crew thought the autothrottle was controlling their plane’s airspeed. It was not. They had not configured it correctly. Since the crew thought that they had handed that important part of flying to automation, they did not check their speed. The result: disaster.

I come to this lesson with some sympathy for the machines. During my surgery residency in the early 2000s, I spent a research year in surgical robotics, operating an early system called Zeus. I believed then, and believe now, that the robot can be a steadier pair of hands than mine. What it cannot be, however, is a pair of eyes that cares how the case ends. As robotic platforms spread through general and pediatric surgery and begin to gain autonomous features, the Asiana lesson applies directly: Automation is a crew member, and crew members get monitored. The surgeon at the console who trusts the machine the way that crew trusted the autothrottle is flying a stable approach right up to the seawall.

Fixation is the quiet killer

The third lesson comes from United Flight 173, a DC-8 that circled Portland, Oregon, in December 1978 while the crew troubleshot a landing gear indicator light. They worked the problem with care and professionalism, but while doing so, their fuel ran out. Ten people died in a crash caused by a burned-out bulb and a crew so fixated on one malfunction that nobody watched the gauges. The gear, investigators found, had been down and locked the whole time. That accident, more than any other, launched Crew Resource Management, the training that reshaped how crews divide attention.

Surgeons are trained to focus. That focus, however, can be dangerous. It is important to maintain situational awareness while focused. The bleeding vessel that consumes the surgeon while the anesthesiologist quietly fights a bigger problem on the other side of the drape. The difficult dissection that swallows an hour before anyone asks whether the plan is still the right one. The defense is to build a crew in which each member owns the whole picture, not just their own panel, and expect anyone in the room to say the equivalent of “we are getting low on fuel” if there is a problem.

The sterile field protects the patient from what we carry into the room on our hands. The sterile cockpit protects the patient from what we carry in our heads. Aviation needed wreckage to learn these lessons. Surgery has the rare privilege of borrowing them secondhand, and we have taken the checklist and left the rest on the table. I would like us to go back for the rest.

Colin G. Knight is a board-certified pediatric surgeon practicing on the Treasure Coast of Florida at HCA Florida Lawnwood Hospital. He is a clinical assistant professor of surgery at the Florida State University College of Medicine and at the Florida International University Herbert Wertheim College of Medicine.

He earned his undergraduate degree at Yale University and his medical degree at the University of Virginia. Before his surgical training, he served four years on active duty in the United States Air Force as a flight surgeon, work that shaped his interest in operating-room safety. He completed his general surgery residency at Allegheny General Hospital and his pediatric surgery fellowship at Children’s Hospital of Michigan.

His research spans minimally invasive and robotic pediatric surgery as well as the management of pediatric appendicitis, with work appearing in the Journal of Pediatric Surgery, the Journal of Laparoendoscopic and Advanced Surgical Techniques, and Archives of Surgery. He can be found at ped-surg.com and shares updates on LinkedIn, Instagram, and X.