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POSITIVE SAFETY CULTURES: Developing team players

December 1, 2005
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Three days after Christmas in 1972, Eastern Airlines flight 401 nose-dived into the Florida everglades, killing 99 passengers and crewmembers. The wide-body L-1011 jet had developed a mechanical problem — a burned-out landing gear indicator bulb. Struggling for several minutes to remove the bulb, the three-man crew failed to notice the autopilot somehow disengaged, and apparently failed to respond to a loud accompanying alarm.

Instead of holding at its assigned altitude of 2,000 feet, the jet headed for the swamp. Finally, eight seconds before impact one of the crewmembers noticed the jet was plummeting and alerted his crewmates. In the remaining seconds, no one took any evasive action.

Focus on people skills

The Eastern 401 story is a classic case of what can happen when a work crew fails to manage the resources at hand to solve a problem. As a result of such accidents where human error was determined to be a major contributing cause, United Airlines established in the early 1980s the first Crew Resource Management (CRM) program. Today crews use CRM for training in specific people skills — effective communication and feedback, enhanced teamwork, group problem-solving, effective workload distribution, shared situational awareness, and heightened sensitivity to the impact of distress on individual and team performance.

And the current generation of CRM programs extends beyond the cockpit crew to include flight attendants, air traffic control, ground maintenance — any and all resources supporting safe and effective flight.

Training crews everywhere

CRM is not unique to aviation. Around the time the first CRM programs were developed for pilots, the highly publicized Three Mile Island incident shook the nuclear industry to its core. Investigations pointed to poor communication, coordination, and teamwork — human error of the sort targeted by CRM programs — as a major contributing cause of the near-meltdown. My local public utility was part of the investigation, and since I was consulting with the utility at the time, I had the opportunity to help build a team-skills training program that led to the CRM-type team training programs common in the nuclear industry today.

In both aviation and the nuclear industry it’s estimated that human error is a major contributing cause in as many as 70-80 percent of all accidents. Either crew-generated mistakes actually trigger the accident, or the crew fails to correctly diagnose and solve a correctable mechanical or environmental problem. There is every reason to expect these human error figures apply to other work settings as well.

And so we find CRM techniques used explicitly by firefighters, off-shore drillers, many types of military teams, and medical operating-room teams, just to name a few of the more visible and publicized applications.

Case study in multiple failures

The core methodology of CRM can potentially help everywhere workplace safety is a concern — which is, of course, everywhere.

Consider this scenario: A quarry worker hurries to get trucks loaded with stone. Previous equipment problems with his loader have caused him to fall behind. He cuts corners to get material shipped out — including not keeping his supervisor informed to his current location and status.

In a rush, he neglects a required safety procedure, failing to leave the cab and physically check behind his loader before starting it and backing up.

Meanwhile, a maintenance man responds to a call to come to that part of the quarry to work on a different piece of equipment. The directions to him are unclear. He arrives in the designated area, sees a stopped loader, gets out of his truck and walks behind it. Mistakenly he thinks it is the equipment he is supposed to work on. But he never checks in with his supervisor. Bent down behind the loader, he is not seen by the loader operator. Hurried and distracted, the operator quickly starts the loader and backs up, running over and fatally injuring the maintenance man.

What caused this accident? CRM tools emphasizing situational awareness, awareness of personal distress, and good communication practices such as questioning and verifying directions and instructions might have prevented this tragic outcome.

Chain of errors

It’s common for this type of chain of events to occur. Operators who are balancing multiple priorities get overloaded and/or miss details, commit errors of commission or omission, which compound. In these cases, the accident “chain” might have been interrupted at any of a number of points by the use of the specific behavioral strategies of CRM. The techniques of CRM aim to boost shared awareness, understanding, and safety accountability across a wider range of resources than just the individual operator. Beyond focusing on the behavior of the individual, it’s important to look at the overall safe behavior of the entire crew, since they work jointly and collaboratively as a unit to effectively manage all the resources at their disposal. This is the critical perspective that the CRM methodology brings to the overall safety effort.

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