There’s a new book I have to get to on systems thinking.
I have to admit I was completely sold by the headline: How having power is like having brain damage: a new book explains why systems fail. When we’re in charge, we are impulsive and ignore others’ perspectives.
The reason this appeals to me as a technical writer is that it provides solid examples of why processes and procedures matter. There are lessons from the airline industry that apply to all sectors:
Since the 1970s, a series of fatal accidents have forced changes in the airline industry. In the bad old days, the captain was the infallible king of the cockpit, not to be challenged by anyone. First officers usually kept their concerns to themselves, and even when they did speak, they would only hint at problems. Organizational researcher Karl Weick described their attitude like this: “I am puzzled by what is going on, but I assume that no one else is, especially because they have more experience, more seniority, higher rank.”
But as the industry grew, aircraft, air traffic control and airport operations became too complex for this approach to work. The captain was king, but the king was often wrong. There were too many moving parts and they were too intricately connected for one person to notice and understand everything.
Captains and first officers usually alternate flying the airplane. The flying pilot manipulates the primary controls. The non-flying pilot talks on the radio, runs through checklists, and is expected to challenge the flying pilot’s mistakes. About half of the time, the captain is the flying pilot, and the first officer is the non-flying pilot. In the other half, the roles are switched. So, statistically, roughly 50 per cent of accidents should happen when the captain is flying the plane, and 50 per cent when the first officer is in charge of the controls. Right?
In 1994, the NTSB published a study of accidents due to flight crew mistakes between 1978 and 1990. The study reported a staggering finding. Nearly three-quarters of major accidents occurred during the captain’s turn to fly. Passengers were safer when the less experienced pilot was flying the plane.
Of course, it’s not that captains were poor pilots. But when the captain was the flying pilot, he (and most often it was a “he”) was harder to challenge. His mistakes went unchecked. In fact, the report found that the most common error during major accidents was the failure of first officers to question the captain’s poor decisions. In the reverse situation, when the first officer was flying the plane, the system worked well. The captain raised concerns and pointed out mistakes and helped the flying pilot understand complex situations. But this dynamic worked only in one direction.
All this changed with a training program known as Crew Resource Management, or CRM. The program revolutionized the culture not just of the cockpit but also of the whole industry. It reframed safety as a team issue and put all crew members — from the captain to the first officer to the cabin crew — on more equal footing. It was no longer disrespectful to question the decisions of a superior — it was required. CRM taught crew members the language of dissent.
Parts of CRM sound obvious, even outright silly. An important part of the training, for example, focuses on a five-step process that first officers can use to raise a concern:
1. Start by getting the captain’s attention. (“Hey, Mike.”)
2. Express your concern. (“I’m worried that the thunderstorm has moved over the airport.”)
3. State the problem as you see it. (“We might get some dangerous wind shear.”)
4. Propose a solution. (“Let’s hold until the storm is clear of the airport.”)
5. Get an explicit agreement. (“Does that sound good to you, Mike?”)
These steps sound barely more sophisticated than what we might teach a child about how to ask for help. Yet they were rarely followed before CRM came along. First officers would state a fact (“the thunderstorm has moved over the airport”) but would hesitate to get the captain’s attention and express how concerned they were, let alone propose a solution. So even when they tried to express a grave concern, it often sounded more like a casual observation.
CRM was a huge success. Since it took hold in U.S. commercial aviation, the overall rate of accidents involving flight crew mistakes has declined sharply. And whether the flying pilot is the captain or the first officer no longer matters. In the 1990s, just half of the accidents — rather than three-quarters — happened when it was the captain’s turn to fly.
The program works because it gives everyone, from baggage handlers to pilots, a sense of purpose. The message is that every single person can make an important contribution to safety, and everyone’s views are important. And, as Daniel Pink explains in his book Drive, this approach — giving people a sense of purpose and autonomy — is often the most effective way to motivate them.
The ideas behind CRM have also spread to other fields struggling with increasingly complex operations, like firefighting and medicine. In a 2014 article in the Journal of the Canadian Dental Association, Dr. Speers and his co-author, dentistry professor Chris McCulloch, described what Crew Resource Management would look like in the dental office.
“Dentists need to minimize hierarchy in their operatories by creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem,” they wrote. “A team member may see something the dentist is oblivious to, such as undetected caries [cavities] or a tooth that is about to receive inappropriate treatment. Dental team members should be encouraged to cross-check each other’s actions, offer assistance when needed, and address errors in a non-judgmental fashion.”
But learning to embrace dissent is hard. When Crew Resource Management was introduced, many pilots thought it was useless psychobabble. They called it “charm school” and felt it was an absurd attempt to teach them how to be warm and fuzzy. But as more and more accident investigations revealed how failures to speak up and listen led to disasters, attitudes began to shift. Charm school for pilots has become one of the most powerful safety interventions ever designed.