Sterile Cockpit, Sterile Crew

“Sterile cockpit” is a mandatory aviation procedure for all U.S. airlines. It has nothing to do with germs or viruses but is all about keeping the air crew’s environment free of distractions that might compromise safety.

The idea has occasionally been applied to ambulance operations and has much that can benefit EMS. As a pilot for 40 years and a paramedic for 22 years, I know both sides of this story. 

Few would argue that our EMS, fire and even aeromedical safety records (helicopters and fixed-wing) are satisfactory. Truth be told, our record of getting to and from scenes safely isn’t good. Can we do better? If we adopt a “sterile crew” concept, has it been proven? The answer to both is yes, and we are way past due. 

Cockpits and Beyond

Sterile cockpit rules came about because many airline crashes had a common theme: pilot distractions. A pivotal incident was a 1974 Eastern Airlines flight into Charlotte that crashed during approach in low visibility. The National Traffic Safety Board (NTSB) found “the flight crew engaged in conversations not pertinent to the operation of the aircraft. These conversations covered a number of subjects, from politics to used cars.”¹ Further, the discussion “continued throughout the remainder of the approach and which contributed to the accident.” This nonessential chatter directly contributed to the failure of the pilots to properly monitor the approach and altitude. Many died.

It was not until 1981 that the Federal Aviation Administration (FAA) published the sterile cockpit rule (14 CFR 121.542 and 135.100).² This is not a casual suggestion for pilots; it is binding—fail to comply, and you stop flying. It has become an aviation fundamental, and as long as there are pilots at the controls, sterile cockpit procedures will likely be mandated.

Sterile cockpit is just not the right term for EMS and fire departments. What we do have are crews. The aviation industry developed the term CRM, which in the beginning stood for cockpit resource management.

Soon after it was put into effect, we realized CRM is not confined to the bubble of the cockpit but extends to the entire crew working and supporting the operation: the flight crew, ground crew, cabin crew, dispatchers, etc. CRM was broadened to crew resource management. So right here, right now, let’s not make the same error: Let’s develop the same sterile crew concept for EMS, firefighters and aeromedical personnel. 

Keep Your Head in the Game

There are four sections to 14 CFR 121.542. First:

(a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft.

What does this mean for EMS or fire departments? Let’s change the wording to fit what we do.

EMTs and firefighters shall not perform any duties during a critical phase (e.g., lights and siren) of a call except those duties required for the safe operation of their vehicle. Dispatchers or management shall not engage in activities or make requests or directives after a crew has been dispatched that are not directly related to their call.

Here’s what this means: Once the tones drop for a call, the EMTs and firefighters in the vehicle will only engage in the duties needed for the safe conduct of the call. Personal phones are put away. No personal text messages by either person. No eating. No conversation not directly related to the call. Chit-chat is shut down—you keep your head in the game.

Dispatch shall not, for example, ask, “What is your off time?” This type of question is not directly related to the safe operation of the call, and you would simply answer “sterile crew” and discuss it with dispatch after the call is complete.

Can you talk while lights-and-siren? Yes! However, the discussion must directly relate to the call. For example, it would be appropriate to mention, while traveling to an MVC, to remember to don reflective vests, take additional equipment you might need, directions or anything else you know about the scene. 

What happens if you get a personal or a company text message or phone or radio call while running lights-and-siren? This is common and will continue even in a perfect system. Frequently systems will send additional dispatch information via text or CAD, or perhaps a pager. These messages often clarify what was initially given verbally and can include additional information that’s important to the call. How do you look at these messages while running lights-and-siren? Pilots have the same problem.

Airlines initially made a mistake in how they handled this. The pilot flying was called just that, the “pilot flying,” while the other pilot was the “pilot not flying.” These were the official terms! But it generally implied that while one person was working (flying), the other one was not engaged. Sometimes this was the case! Now we use the terms “pilot flying” and “pilot monitoring.” This terminology suggests both pilots are active. 

Similarly, there have been occasions when the person driving the ambulance or fire truck has been doing everything: conducting radio calls, reading text messages, looking at the map, all while the person next to them is disengaged. Let’s be honest, four firefighters in a truck going lights-and-siren to a scene can get crazy. Are they reducing their driver’s workload, or are they a distraction—telling stories, the latest joke, complaining about somebody? How about EMS ride-alongs? Those days of others in the vehicle distracting the driver need to stop. 

Now ask yourself, where is the radio handset located in your unit—next to the driver or the right seat of the cab? When we get a radio call from dispatch, there’s a powerful urge to answer it. Some really important information might be available. But here’s where you work together: Let the driver drive with both hands available while the other person answers the radio. You work as a crew.

How does a pilot handle a text message while taxiing a plane? The pilot monitoring would simply say, “I’m heads-down.” This tells the pilot flying that he will evaluate the message and be briefly unable to look out the right side for traffic. When he’s done, he’ll brief the pilot on the message. It is common to hear in the cockpit “heads-down” and “I’m back with you.” These are clear communications between two people. What about looking down at the map? Same thing: just announce it. Everyone is engaged, and no one is distracting.

Permission Denied

The next part of the aviation regulation is important.

(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties.

What does this mean? The rule applies to everyone, including, for us, the firefighters in the back of the fire truck, the ride-along in the ambulance and even the dispatcher. But in any ambulance, fire or aeromedical call, there is someone in charge. In an airplane it’s the PIC (pilot-in-command). The person who is in charge shall not permit others to distract.

How do you handle this in the real world? If we were flying and about to begin our approach and a third pilot said, “I just realized we might be able to make the game tonight!” as the PIC (likely with a touch of irritation in my voice), I’d say, “Sterile cockpit reminder.” If it happened again, I would say “Sterile cockpit,” followed by a meeting after the flight to decide what level of corrective action or training needed to be applied.

What should you do in this situation in EMS? In the beginning you will do well just to say, “Sterile crew, please.” With the next lapse, “Sterile crew.” It doesn’t matter if you’re the person in charge. In fact, once I had a third pilot mention something not related to our duties during climb-out (“Hey, you guys want anything to eat from the back?”), and both the first officer and I turned around and said in unison, “Sterile cockpit!” Two of us laughed, and the other pilot later apologized. It was a bit of a smackdown.

Wheels Rolling

When are you a sterile crew? For airlines it’s pretty easy: In the air, when below 10,000 feet. When on the ground, if a tire is rolling. 

(c) For the purposes of this section, critical phases of flight include all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

This can’t just be cut and pasted for prehospital use, but neither is it that hard to adapt. Say the tones drop for a call as you’re driving. Let the other EMT or firefighter answer the radio and text message. How about when you’re arriving at the hospital and the driver is backing up? Wait until you’re stopped to give the dispatcher your time and mileage. When you’re backing up, don’t multitask. We’ve all heard how hospitals will throw themselves at the backs of ambulances when drivers are a tiny bit distracted. I was amazed the first time I saw that. I have also had curbs relocate under my tire as if by magic.

Say you’re leaving a scene with a family member in the front right seat; the EMT is driving, and the paramedic is attending the patient. How do you enforce the sterile crew concept there? Sterile crew applies no matter who else is in the vehicle! You brief the passenger to wear their seat belt, of course, then just add, “On the way to the hospital, my job is to deliver you folks safely, so I will not be able to chat. I know you may have questions, and we’ll try to get them answered when we’re not moving.”

Technology Troubles

Wireless communication can get out of control. Here’s the short version of the aviation standard: If it isn’t directly related to safe operations, you can’t use it. The individual in charge also has the responsibility to stop any activity unrelated to safety.

(d) During all flight time as defined in 14 CFR 1.1, no flight crewmember may use, nor may any pilot in command permit the use of, a personal wireless communications device (as defined in 49 U.S.C. 44732(d)) or laptop computer while at a flight crewmember duty station unless the purpose is directly related to operation of the aircraft, or for emergency, safety-related or employment-related communications, in accordance with air carrier procedures approved by the Administrator.

The fronts of ambulances and fire trucks are awash with computer screens, text displays, radios and at least one GPS. Personal computers and tablets get closed the moment sterile crew goes into effect. No phone calls to/from friends while en route to a call. If a tire is rolling, everyone focuses on the task.

Say while you’re traveling your dispatcher sends a text message advising that after your call, you are to go to your base for some vehicle maintenance. Here dispatch is in violation of multiple aspects of sterile crew! They know you’re on a call and contacted you with a non-safety-related message. If this was by radio, I’d suggest you simply reply, “Sterile crew.” If it was a text, don’t even answer. Either way, after the call you should have a chat to resolve the distraction.

What about your computer-aided dispatch system? Again, the driver doesn’t engage it if the tire is rolling. The other person would announce “I’m heads-down” and take care of the message, then update the driver on any need-to-know-right-now items. If you’re the only one in front and get a company message, pull over—don’t text and drive. If the tire’s not moving, it’s hard to hit another stopped car. I’ve stopped planes while taxiing to work on problems many times.

Aeromedical

For this group use the term sterile cockpit—it’s understood in the aviation community. For EMS and firefighters cockpit just doesn’t fit. I submit that sterile cockpit rules for aeromedical, helicopter and fixed-wing need to be a little different. For one, many helicopters don’t have tires. And aeromedical does not fly under the Federal Aviation Regulation (FAR) rules airline pilots use (parts 121 and 135) but rather part 91. 
Part 91 rules govern general aviation and do not include federally mandated sterile cockpit restrictions.

There is a long list of rules to follow, but sterile cockpit is not among them. Aeromedical pilots know they’re overdue for these rules. In the meantime, individual companies can require sterile cockpit rules as part of their flight operations.

For fixed-wing aeromedical operations, the same sterile cockpit procedures as airlines would apply as currently written. The medical crew in the back needs to be trained on sterile cockpit procedures so as to not cause problems. It takes training for the entire company to comply—that means the ground crew, flight crew, medical crew, dispatcher and boss. 

For helicopter-based aeromedical, since there is no tire to roll, organizations need to decide when sterile cockpit will start and end. I suggest that if the rotor is turning even a tiny bit, sterile cockpit should be in effect. A moving rotor blade deserves respect.

Helicopters do not routinely fly above 10,000 feet but the current regulation allows for this with: “and all other flight operations conducted below 10,000 feet, except cruise flight.”² It ends at the top of the climb and begins again at the top of the descent.

Conclusion

Take action. Talk to those you work with about sterile crew; maybe show them this article. Start putting it into effect. Look at your most recent accidents—could you have done more to prevent them? 

Change can be difficult. It takes leadership from every level to make it happen, but you can start right now with yourself. Sterile crew is based on a concept that’s been proven in aviation and can be adapted by EMS, fire departments and aeromedical providers. Go ahead—change and adapt. 

References

1. National Transportation Safety Board. Accident Reports: Eastern Air Lines Inc., Douglas DC-9-31, N8984E, https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR7509.aspx.
2. Government Publishing Office. 14 CFR 121.542—Flight Crewmember Duties, https://www.gpo.gov/fdsys/granule/CFR-2017-title14-vol3/CFR-2017-title14-vol3-sec121-542.

Sidebar: A Tool Anyone Can Use

When else are we sterile crew? Here’s the beautiful thing: Anybody can call it, any time. 

If you see a situation developing in which you want everyone to pay attention and perhaps listen to some radio traffic from other units that need help, just call “sterile crew.” You’ve been working a tense cardiac arrest for 20 minutes and someone expresses some dark humor? Snap the focus back to the task with “sterile crew.” Sort out the problem later. Maybe the conversation has suddenly gone in the wrong direction with family members present. It’s a quick and easy way to call a halt to it. 

Sterile crew can be very short duration. For example, your partner is outside helping you back up the unit at the hospital, and you are literally the only one in the truck. Don’t make calls to dispatch as you back up. Or perhaps you’re going to unload the patient from the back—stay in the game; sterile crew applies. 

Capt. Dick Blanchet (Ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years on the Boeing 747 with more than 21,000 flight hours. As a USAF pilot, he flew the C-9 Nightingale aeromedical aircraft for five years.