Beyond the pilot analogy

Dear editor,

We read with interest Regaieg’s conceptualisation of the on-call intensivist as a “pilot in the storm” [1]. We share the authors’ intention: strengthening ICU safety by learning from other high-reliability industries. The analogy is particularly helpful when it reinforces structured handovers, anticipation, Crisis Resource Management (CRM), teamwork, safety checklists, and high-fidelity simulation. Critical care medicine has been actively integrating these domains for decades, and many units worldwide continue to invest substantial institutional resources into these models.

At the same time, aviation lessons translate best when we state clearly where ICU work differs. Doing so does not weaken the analogy; it helps it. It allows us to adopt what transfers cleanly (e.g., structured communication and team training) while addressing ICU-specific risks with healthcare-specific solutions.

Checklists help – when they support bedside work

Checklists gained traction in critical care because ICU work is characterised by high task density and frequent handoffs. Donchin and colleagues described roughly 178 activities per patient per day. In such a densely complex matrix, even an exceptional error rate of 1% per activity translates to nearly 1.7 errors per patient daily [2]. This sheer volume illustrates exactly why standardised safety bundles (such as those utilised to dramatically reduce central line-associated bloodstream infections) are highly appealing: they act as vital cognitive offloading mechanisms, preventing the accumulation of active failures when a clinician’s working memory is inherently saturated [3].

Hitherto, checklists only function reliably when embedded within a broader, non-punitive safety culture [4]. When checklists become documentation rather than cognitive support, they stop helping at the bedside. The goal is not more checklists, but better ones—short, team-visible, action-oriented, and embedded in workflow. When implemented within a broader safety programme and culture, bundles can produce major improvements.

Intensive care is human work: ethics, relationships, and emotional impact

Aviation metaphors understandably foreground technical performance under uncertainty. In critical care, however, uncertainty is frequently relational, prognostic, and deeply ethical. Clinicians do not merely navigate physiological storms; they must routinely guide patients and their surrogate decision-makers through profound grief and value-laden choices under immense time pressure [5].

Consequently, shared decision-making and structured communication are core competencies of the intensivist, particularly during night duty solitude. Empirically validated frameworks, such as the VALUE mnemonic (Value, Acknowledge, Listen, Understand, Elicit), provide a structured, systematic approach to these interactions, analogous to aviation protocols, but applied directly to human empathy. This intense emotional labour extracts a significant psychological toll. Moral distress is widespread across critical care environments and can affect professional well-being and retention [6]. Including this reality within the analogy helps ensure that “high reliability” in the ICU includes not only technical safety tools. It should also include deliberate support for ethical reflection, communication, and emotional impact.

There is no “autopilot” in medicine: night work can be a daytime-level continuum

The “autopilot” image is useful for disciplined monitoring, yet ICU work rarely has a true cruise phase. Even when physiology appears stable, clinicians make continuous micro-decisions: interpretation of subtle laboratory trends, interruption management, anticipatory adjustments, and frequent re-alignment of therapeuthic goals. This sustained cognitive and emotional effort provides context for burnout, which remains highly prevalent among ICU physicians and nurses [7]. Burnout is also associated with poorer quality of care, reinforcing that clinician wellbeing is a patient-safety issue [8].

Importantly, although the correspondence focuses on night duty, ICU nights are not reliably quieter. Many on-call shifts function as a continuum of daytime-level activity: admissions, urgent procedures, troubleshooting, and high-stakes conversations. What differs at 03:00 is often not the work itself, but the clinician’s cognitive reserve. Sleep deprivation and circadian disruption severely and objectively impair specific neurocognitive domains, most notably processing speed, working memory, cognitive control, and psychomotor vigilance; the exact, irreplaceable faculties required for safe intensive care [9–11]. Naming this difference strengthens the aviation comparison and points to a key area where healthcare is still catching up.

Fatigue: aviation manages it structurally; healthcare is still building the equivalent

Recognising these acute neurocognitive deficits strengthens the aviation analogy by pointing directly to its greatest operational success: structural fatigue risk management. The European Union Aviation Safety Agency (EASA) enforces uncompromising Flight and Duty Time Limitations (ORO.FTL), explicitly addressing flight/duty time limitations and fatigue-risk principles [12].

By stark contrast, healthcare worker protections remain dangerously supple. The EU Working Time Directive (2003/88/EC) provides minimum labour standards, but its intent is routinely diluted by long reference periods for averaging hours and prevalent individual opt-out clauses [13]. If aviation is to be viewed as the ultimate aspirational comparator for medical safety, protecting rest and recovery may be among the most meaningful “imports,” alongside checklists and simulation.

Simulation as an interprofessional bridge

We concur that simulation represents the most promising bridges between aviation and critical care. ICU simulation supports technical skills, teamwork, and communication, particularly when interprofessional and scenario based [14]. To reflect real ICU night challenges, simulation programmes may benefit from training the whole team (nurses and physicians together) and targeting handover structure, escalation, difficult conversations, and emotional skills- competences that matter when workload and fatigue intersect [15].

Conclusion

Regaieg’s analogy is a useful prompt for continuous improvement in ICU safety culture [1]. Making ICU-specific features explicit—ethical deliberation, continuous cognitive work without a true “autopilot,” and the need for more reliable fatigue protection—helps the analogy work for us rather than constrain us. In that sense, aviation can inspire not only checklists and simulation, but also the system conditions that allow teams to deliver safe, humane, and sustainable intensive care.

Abbreviations

CRM

Crisis resource management

EASA

European union aviation safety agency

EU

European union

ICU

Intensive care unit

VALUE

Value, acknowledge, listen, understand, elicit

Author contributions

BLV and SAC conceived and drafted the manuscript and approved the final version.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.