The Role of Human Factors in Airway Management
Time 15-18 Minutes
The Essentials
Martin Bromiley in His own words – The Elaine Bromiley story
Elaine Bromiley and the Moment Medicine Had to Listen
The death of Elaine Bromiley was not the result of ignorance, incompetence, or lack of effort. It occurred in a well‑resourced operating theatre, staffed by experienced clinicians, all of whom were trying (earnestly and repeatedly) to help her.
That is precisely why the case matters.
When Elaine Bromiley died, her husband, Martin Bromiley, did something extraordinary. He refused to let the explanation end with technical failure or individual blame. Instead, he asked a far harder question:
“Why do good people, with good intentions and good training, sometimes make catastrophic decisions together?“
His plea was not for better equipment or more rules. It was a call for medicine to confront human factors—how stress, hierarchy, fixation, language, and culture shape behavior at the bedside. The Elaine Bromiley case is not an airway case. It is a human factors case that happened to involve an airway.
What Went Wrong Was Not a Skill Deficit
During Elaine Bromiley’s case, multiple attempts were made to secure the airway. Each attempt was reasonable in isolation. Each was performed by a capable clinician. Yet collectively, they formed a pattern of fixation—a narrowing of attention around a failing plan.
This was not because the team did not care. It was because, under stress, human beings default to action, especially familiar action. We keep doing what we know how to do, even when it is no longer working.
Martin Bromiley recognized this immediately. As a commercial airline pilot, he had seen the same pattern play out in aviation accidents. His profession had learned, through hard lessons, that disasters rarely stem from a single technical error. They arise from predictable human behaviors: confirmation bias, authority gradients, loss of shared situational awareness, and the failure to speak up.
Medicine, at the time of Elaine’s death, had barely begun to acknowledge this.
Martin Bromiley’s Plea
The Bromiley case forced medicine to confront an uncomfortable truth: technical excellence is not enough. Without cognitive guardrails, teams will repeat the same errors under pressure, even when they know better.
Specific individual behaviours enhance safety. Other behaviours reduce safety. There’s a good evidence base in other industries. In healthcare how do we encourage & train behaviours? In healthcare disaster after disaster this seems a common issue. It’s not just one hospital.— Martin Bromiley
(@MartinBromiley) January 24, 2020
Why This Case Still Matters
Elaine Bromiley’s death changed the way airway management is practiced. Martin Bromiley’s enduring contribution is the insistence that medicine must design its systems for real humans, not ideal ones.
The case asks every clinician a hard question: When the plan is failing, will you recognize it?
Will you have the language, the permission, and the cognitive tools to change course in time?
That question is Elaine Bromiley’s legacy.
What Comes Next
In the next part of the story, we explore how the lessons of the Elaine Bromiley case catalyzed the development of a new kind of cognitive tool—one designed not for idealized clinicians but for real humans under pressure.
This tool does more than offer a checklist or an algorithm. It provides a shared language, a shared frame, and a way to surface the conversations that matter most when airway management becomes uncertain.
At its core is a simple but critical aim: to help teams recognize when progress has stopped, reduce fixation, and protect what ultimately matters most—oxygenation—by anticipating the human factors that so often undermine it.
What’s Next
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