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On December 14, 1799, 3 prominent physicians-Craik, Brown, and Dick-gathered to examine America's first president, George Washington. He was complaining of severe throat symptoms and was being treated with bloodletting, blistering, and enemas. Dick advised performing an immediate tracheotomy to secure the airway. Both Craik and Brown were not keen on trying tracheotomy and overruled that proposal. Washington was not involved in making that decision. He most likely had acute epiglottitis that proved to be fatal at the end. If Dick had prevailed, a tracheotomy could have saved Washington's life. Human factors analysis of these events shows that his physicians were totally fixated on repeating futile treatments and could not comprehend the need for a radical alternative, like tracheotomy. That was aggravated by an impaired situational awareness and significant resistance to change. Leadership model was also based on hierarchy instead of competency, which might have also contributed to Washington's death.