During the period of 1959 through to 1989 flight crew actions attributed as a cause to 70% of accidents (Salas, Shuffer & DiazGranados, 2010).
Over the last 30 years there have been several high profile accidents that have involved a significant loss of life that have been attributed to pilot error. However what has not been measured and would be significantly harder to measure are the lives saved by positive team work and effective leadership shown by captains under sometimes dire circumstances.
Human error features highly as a casual factor in a high level of accidents. The challenge is to find ways to reduce the impact of these errors. It is unlikely that error can be eliminated, however it’s been shown that team environments can be significant in identifying the error and mitigating it before its negative downstream consequences can have effect (Salas, Shuffler & DiazGranados, 2010).
Teams have become widely used in a range of organizations, as they provide a broader pool of cognitive resources and task-relevant knowledge, skills, and abilities than just a single individual. For aviation, teams provide a redundant system in which individuals can monitor and provide back up for one another, reducing the likelihood that errors will go unnoticed.
This page will look at how successful teamwork and leadership has led to successful outcomes in the face of adversity.
Aircraft incident Examples used
- United Airlines flight 232
- British Airways flight 9
- US Airways flight 1549
- Qantas flight 32
For a team to be effective, team members must have both teamwork and task work skills. Task work involves skills that are required for team members to perform tasks in this case core flying skills. Team work skills focus on behaviors and attitudes required for teams to function in order to accomplish the task at hand.
Teamwork is defined as a set of behaviors, cognition's, and attitudes that are enacted in order to achieve mutual goals and meet the demands of the outside environment. (Salas, Shuffler & DiazGranados, 2010).
Salas, Shuffler and DiazGranados go further that crews must be able to perform both teamwork and task work skills. The crew must be able to efficiently and effectively perform the task at hand while teamwork skills are also crucial for effective coordination and communication between crew members.
Team competencies are requirements for a team to work effectively.
Cannon-Bowers and colleagues (as cited in Salas, Shuffler and DiazGranados, 2010) identified a set of eight major team work skills
4. Decision making
5. Interpersonal relations
6. Leadership / team management
7. Performance monitoring / feedback
8. Shared situational awareness
Looking closer at some high profile accidents such as, United 232 and its total hydraulic failure at Sioux City, US airways 1549 that successfully ditched in the Hudson River, QF32 that dealt with multiple systems failure and British airways flight 009 that flew through volcanic Ash and successfully restarted all its engines for a safe landing.
In all the successful outcomes all the team members had the required task work skills and performed them diligently and admirably under pressure. They also all exhibited all the above team competencies. Particularly in British Airways flight 009 where not only had they lost 4 engines, they had lost electrical power making communication hard, and also the oxygen mask for the First Officer was broken compounding the effect on the crew.
As previously stated a high performing team show the above competencies and share a common goal, however a team can only be so effective without a leader.
A leader provides the team with a single figure to make the decision after all the information has been shared, but not only that the leader can also get the best out of his team individuals, allowing them to perform their strengths and yet addressing their weaknesses.
The leader or in this case the Captain also assumes total responsibility for the teams actions and inaction's.
In the case of the Sioux City DC10 hydraulic failure, the captain very quickly realized he was not the correct person to be manipulating the throttles as the captain in the third seat has the better skills to achieve it, however it did allow him to monitor the overall situation. To delegate to a more senior pilot in this case with greater experience on type, despite never having flown the DC10 on just throttles. This decision may have been the critical difference between saving 187 lives or none.
On Us Airways flight 1549 Captain Sullenburg very quickly assumed control of the aircraft and radios after the double engine failure, allowing the first officer to concentrate solely on the checklist for an engine restart. This was a twofold decision, it allowed the captain to put the aircraft exactly where he wanted it, and it also allowed the first officer to concentrate without interruption on an important checklist. The captain also knew that the first officer was new on type and knew the checklists location quicker than he did, deferring to essentially the first officers recent experience from training.
QF32 again with a large crew of 5 on the flight deck were controlled by the captain, assigned tasks and troubleshooting all while he managed the radios and aircraft whilst monitoring the overall situation.
Effective captains are managers, and managers extract the best from people by assigning the correct tasks to the correct people and monitoring the overall situation.
The captain is responsible for making the decisions but he/she is supported by the input from the entire crew, both those individuals in the cockpit but also on the ground (i.e., air traffic control, dispatch, maintenance).crews that work effectively can make better decisions than individuals because the multiple eyes, ears, hands, and minds can increase their cognitive capacity and crews can offer multiple options, share workload, and often avoid traps to which individuals are often susceptible.
The importance of a shared mental model
Shared mental models allow individuals within a team to be able to describe a common goal that they are working towards as a team. By having this shared picture it allows individuals to be able to predict and explain the behavior of the world around them. In essence the team are all pulling in the same direction; the common goal.
Shared mental models allow the team to anticipate actions, which results in improved team functioning and more effective performance outcomes. Teams that hold shared mental models have improved communication, strategy formation and coordination.
During a flight deck crisis, having a clear shared mental picture of the desired outcome is key in managing individual mental models to achieve a successful outcome.
American Airlines 1549 that ditched in the Hudson was a great example of shared mental model; captain sullenburg never had time to brief the cabin crew other than in his PA to brace for impact. The cabin crew knew immediately they were going in the Hudson and began calling out their brace for impact calls, essentially putting the whole crew on the same page.
Adaptability in an emergency situation
The ability to adapt is a key skill in a high performance team environment such as the flight deck. Groups that engage in adaptive behavior outperform those that do not.
An emergency can range from a simple straight forward task such as shutting down an engine right through to a multiple system failure like QF32 where adaptability was shown to be key in the successful outcome as the crew dealt with over 150 system failures.
In the Sioux City DC10 accident no one had ever flown an airliner on throttle control alone; McDonnell Douglas had deemed it a 1 in a billion chance and thus crews was not trained. Yet, on the day the captain was able to quickly adapt and learn on the spot and adapt quickly enough to bring the aircraft to Sioux City airport saving over a hundred lives.
A team must communicate effectively to have a shared mental model. Communication is an extremely important part of CRM, and has been implicated in 80% of accidents between 1980 and 2000 (Sexton & Helmreich, 2000 as cited in Salas, Shuffer & DiazGranados, 2010).
Crews that participate in proactive communication as well as that which is related to planning and situation assessment tend to perform better under all situations.
A hugely important part of cockpit communication is having open communication lines. The Captain is responsible for setting the correct tone and ensuring that the lines of communication are open. This means having a first officer and crew that are happen to brings things to the attention of the captain without fear of reprisal or Ego.
In US Airways flight 1549 that ditched in the Hudson River, Time was a critical resource and little time was spent wasted in vast communication between both the Captain and ATC. The communication was clear, concise and unambiguous. Interestingly enough the communication between the Captain and his First officer was similar, and yet at all times all people involved knew exactly what was happening and when. US Airways flight 1549 is frequently used on CRM training courses as an example of good communication between crew when in an emergency situation, the ‘less is more’ theory was quite accurate in this case.
It is not unusual for aviation training to focus on accidents and learning’s from negatives. However equally as powerful are learning’s from positive outcomes such as the above incidents.
In all of the above incidents leadership, communication, task work and team work featured as the flights were brought to successful outcomes under extreme conditions.
It may also be fair to say that as Aviation continues to become safer through improved technology and human operator performance improvements, we must not only learn from accidents but shift towards learning from positive outcomes. Incidents are all but impossible to eliminate, however what can be learnt from these events may become even more important as we work towards a 0 accident rate worldwide.
Salas, E., L.Shuffler, M., & DiazGranados, D. (2010). Team Dynamics at 35,000 Feet. In E. Salas & D. Maurino (Eds.), Human factors in aviation (2nd ed.). Amsterdam: Academic Press.
Want to know more?
- British Airways Flight 009 and the Volcanic Ash encounter
- United Airlines Flight 232 and total hydraulic failure
- US Airways Flight 1549, double engine failure after bird strike and sucessful ditching in Hudson River New York.
- Engine failure over Bantam Island, Singapore and subsequent multiple system failures.