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Error and crisis management October 31, 2013

What business can learn from airline accidents

plane in the middle of a forest
Lack of communication is linked to disaster; the aviation industry knows and has acted on this – and it's time business caught on.

Thirty years ago, the aviation industry realized that many errors and airline disasters were caused by a lack of open communication in the cockpit rather than technical problems.

The first report on this area was published by the US Air Force Inspector General as early as 1951, entitled Poor teamwork as a cause of aircraft accidents. It was based on 7,518 accidents. Even back then, the authors suggested teamwork training programs as a means to tackle the problem. Still, it took twenty seven years before this proposal was revisited, ultimately resulting in the first Crew Resource Management – or (CRM) – a set of training procedures for air safety.

Before then, the captain's authority in the cockpit had been sacrosanct and the crew would fear questioning his actions and decisions. Criticism came from the top down, but almost never bottom up. This situation has certainly not been exclusive to aviation.

All of us have met an intimidating superior or two during our careers. However, unlike the aviation industry, most corporations have yet to conduct large-scale research into the interdependence of authoritarian business leaders, and the disasters caused by their single-handed, undebated decision making.

Rather than a neurotic urge to be the one in control, the mindset leading to flawed decisions is something with which we are all familiar. First, there is the desire to get a job done no matter what. In the flight environment this can mean getting too close to a weather front to save time; trying to reduce costs by refueling with the legal minimum only; attempting an approach ahead of an incoming thunderstorm to avoid an alternative airport. In business terms, it could be to generally feel like the person responsible for the entire team and to be convinced that they know best how things are run and done.

Taken to more of an extreme, the "macho" business leader is akin to the macho pilot who wants to see the sky as his or her own playground, a place to prove his or her skills to lesser mortals.

Often these attitudes go hand in hand with the feeling of being untouchable, and being convinced that failure or disaster only ever happen to other people, while the leader is immune to everything. To escape a risky situation by the skin of his or her teeth will simply confirm this conviction. Such feelings of omnipotence may easily lead to impulsive actions and a dangerous impatience to make a decision before having checked whether it is sound.

Equally disastrous is the opposite attitude of sulking or giving up when things go wrong. In the air, this may have fatal consequences; in business it may cause employee disorientation, unfinished or failed projects and costs getting out of hand. A close relation of this kind of resignation is routine behavior and the belief that no matter what we do nothing will ever happen anyway. Either personality type usually results from people caught in a behavioral pattern they can no longer see.

Unfortunately, our companies have not yet established an open system in which these attitudes or patterns can be easily discussed and further consequences prevented. In most cases, they will be noticed by colleagues and whispered about, or mentioned behind closed doors. Conventionally, errors and erroneous behavior are, after all, still stigmatized as deficits and associated with embarrassment, shame, and fear.

Modern error management is different, and requires a different perspective. It accepts errors – and the reasons for them – as an unavoidable part of human behavior. Sure, those who make mistakes may still become annoyed at themselves, but they need not fear ridicule or sanctions from others. Instead, they – ideally with their colleagues – should try to clinically analyze what led to the mistake and attempt to eliminate this to prevent future problems.

It took the aviation captains years to accept CRM, start discussing their decisions with their crew, and invite their feedback. Similarly, business leaders will also need time to readjust to the demands of modern error management. It may be a comfort to know that the majority of captains today will say that they do not view open cockpit communication as a disadvantage but as a relief.

If you have ever witnessed such a communication you will be amazed how easy it can be to mention someone else's mistake calmly and receive an equally calm "thank you.”

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