Modifying the FAA's “sterile cockpit” rule to anesthesia. Icons made by Flat Icon Design and Freepic from

Modifying the FAA’s “sterile cockpit” rule to anesthesia. Icons made by Flat Icon Design and Freepic from

Long before the advent of cellular phones were the early days of powered flight, when fatal accidents were unfortunately routine. Improvement in air safety was required for the development of the aviation industry. Over time, airlines have evolved into the safest mode of transportation. Many of these advances came from the experience of aviators, including the deadly crash of Eastern Airlines Flight 212. On the morning of September 11, 1974, Eastern Airlines Flight 212 departed Charleston, South Carolina, for Charlotte, North Carolina. During the descent into Charlotte, the plane crashed 3.3 miles short of the runway. The cockpit recording of their final minutes revealed multiple conversations on “nonoperational subjects,” including President Nixon’s impeachment proceedings and stock market investments, with one over an altitude alert. The National Transportation Safety Board investigation concluded that the probable cause of the crash was a lack of flight crew awareness due to poor cockpit discipline, enabling a casual and distracted operation ( Nearly all 82 passengers and crew onboard were killed in the crash, including Dr. James Colbert, a prominent immunologist and father to “The Late Show” host Stephen Colbert.

The tragedy helped to improve air traffic safety. In the years following, the Federal Aviation Administration (FAA) published the “sterile cockpit” rule, Federal Aviation Regulations Part 121.542 and 135.100 (; These regulations prohibit pilots from performing nonessential activities during critical phases of flight, defined as flying below 10,000 feet and not cruising. These regulations ensure a disciplined cockpit for taxiing, takeoff, and landing. Fortunately, the FAA’s broad definition of nonessential activities included restricting the use of cell phones and other personal electronic devices (PEDs) well before their rise in usage.

In 2011, Broom et al. referenced the “sterile cockpit” rule in their study of noise and OR staff movement during anesthesia inductions and emergences. They found remarkable levels of both auditory and physical distractions throughout all phases of anesthesia, comparable to the cockpit of Flight 212 (Anaesthesia 2011;66:175-9). Further investigation revealed that some OR sound levels reached the decibel equivalent of a passing truck (Ann Surg 2014;259:1025-33). Fast forward to 2023, and over 1 billion smartphones are sold yearly and 50 years of technological progress have passed since cell phones were invented by a Motorola engineer in 1973. ORs have more sources of distraction than ever before, with up to 24% of anesthesia professionals reporting using their PEDs in the OR and 80% agreeing that PEDs were potential patient care distractors (Ann Surg 2014;259:1025-33).

Despite the prevalence of possible distractions to anesthesia professionals, there is a paucity of data surrounding the interruption of anesthesia workflow and the impact on patient outcomes. However, surgeons have observed that distractions, especially high noise levels, are correlated with a higher level of postoperative complications, including surgical site infections (Surgery 2015;157:1153-6; Br J Surg 2011;98:1021-5). Once PEDs as perioperative distractions are studied further, we expect that the evidence will support minimizing PEDs within the OR and provide an opportunity for anesthesiologists to shepherd high-quality patient care.

While the “sterile cockpit” rule improved aviation globally, there is room for improvement before being applied to anesthesiology. One of these areas is customizing the 10,000 feet cutoff for each flight. While this altitude covers critical phases of most flights, the generalized limit may be insufficient during certain circumstances, especially high-altitude airports near 10,000 feet. Another area of improvement would be redefining the critical moments of flight. Taxiing, takeoff, and landing are critical to flight, but there may be other moments as well, including cruising altitude emergencies.

We suggest a modified, patient-centered “sterile cockpit” rule to minimize the distractions anesthesiologists face, not just with PEDs. We encourage anesthesiologists to reflect on their experience while developing their “sterile cockpit” rules. Is there any part of the anesthesia care plan where distractions could be tolerated without affecting patient care? When? What kind of distractions? Would this type of case impact your answers? Would certain underlying patient conditions impact this rule? How do you minimize distractions during ordinary and extraordinary portions of a case? These answers can help design a powerful set of perioperative regulations that allow anesthesia professionals to maintain appropriate OR discipline.

Consider a minimum “sterile cockpit” during induction and emergence, with only essential perioperative activity. Keep in mind that certain communication would be considered an essential activity, especially between anesthesia residents and their attendings as patients approach emergence. This sterility should be expanded to any other critical moments of the case as needed, including times of hemodynamic instability or surgical milestones requiring distraction-free communication with the surgical team. The anesthesia care team can be provided with institutional recommendations, but the individual teams should define these moments during case planning. To make this possible, institutional mechanisms to free an OR from nonessential activities must exist. Crockett et al. demonstrated effective distraction management during inductions using simple interventions such as an anesthesiologist requesting quiet and collaborating with nursing staff to pause OR music (Anesth Analg 2019;129:794-803).

When an anesthesia provider enacts a “sterile cockpit,” all members of the OR team, including nurses, technicians, and device representatives, must refrain from nonessential activities. Similarly, each member of the OR team should be empowered to recognize and recommend when a situation warrants a “sterile cockpit.” This parallels the “Stop the Line” initiative for patient safety already in place within many hospitals and Veterans Affairs facilities. As time-outs have become universal to ORs, anesthesia providers can incorporate how and when distractions will be handled within time-outs. Electronic anesthesia record checklists and macros can be adapted to document discussion of OR distractions alongside other crucial safety checks, such as verifying preoperative antibiotics.

Just as the growth of modern aviation has relied on air safety improvements, modern anesthesia has relied on and continues to rely on patient safety improvements. Facilitating an anesthesia workflow environment that promotes excellent patient care is necessary as distractions such as PEDs proliferate into the perioperative setting. Contemporary anesthesia involves personalized care plans for each case, which should anticipate and systematically address perioperative distractions. Learning from experience is key to an anesthesiologist’s training, so why not reflect on aviation history to safeguard our patients to the best of our ability?