In the late 1940s following WWII there were two significant influences on commercial cockpit culture. What followed changed aviation safety forever. The first was a result of the massive wartime technology spike, taking planes higher and faster than before but also making the design, test and manufacture processes more reliable.
The second was the transfer of military-style rank from warplanes to airliner cockpits. Aviation had inherited much from the maritime world, including the absolute authority of the captain but this was further reinforced by a pilot group recently demobbed from wartime military service. Aircraft captains assumed the mantle of complete command and more junior members of the crew (there were still several in the cockpit in those days) would think very carefully before challenging it.
The outcomes of these two influences did not really become apparent for many years until the introduction of the flight data recorder and cockpit voice recorder technology. This revealed that while the total accident rate may have been decreasing, the proportion of those accidents attributable to human performance failures was increasing as technical reliability improved. It also proved that the precursors of many accidents had actually been recognised by crew members at the time but their cautionary input had either been too timid or the captain had simply dismissed it.
The industry recognised the need for a solution and numerous theories were tested in the new generation of flight simulators. The eventual outputs were the beginnings of crew resource management (CRM), a now universal training and education programme focusing on non-technical skills such as teamwork, communication, situational awareness, problem-solving and decision making, together with the behaviours which support and promote them. CRM has evolved into an operational management system that makes optimal use of all available resources – technical equipment, people both inside and outside the cockpit, operating and emergency procedures and perhaps most importantly time – to maximise the efficiency and safety of flight.
It wasn’t an entirely smooth transition; for a time captains found themselves being challenged on just about everything, even their choice of meal, as the ‘authority gradient’ tipped back too far the other way but in general it has now settled into a managed process of consultation within the time available, followed by clear decisions from the commander. Breakdowns in CRM continue to contribute to accidents as pilots fail to communicate adequately, deviate from standard procedures or become focused on a single task while overlooking more critical but less obvious issues. At least now we know what we are looking for in the subsequent investigations. Finally, we can’t ignore the fact that the pilots are part of a much larger team and whilst the captain may be a demi-god in the cockpit, back on the ground he answers to a higher authority in management. Pilot behaviours, as with those of any team member, will be strongly influenced by the management and organisational culture within the airline as a whole. Some might argue that it is in this area that the next real gains in aviation safety lie.
How does this translate into healthcare? As with aviation, the first step is to establish if there is a problem or not; if not then forget the whole thing but most would probably agree that there is sufficient evidence to support the need for improvement. Then, in the same way we need to identify and quantify the problem using robust evidence and data – is it technical and the equipment not good enough; is it procedural and we need to find a better way; or is it behavioural as in the case of aviation? If the latter, then it is the enhancement of non-technical skills within the team which offers the greatest opportunities for improvement. Thereafter, an examination of the wider organisational culture could facilitate and promote an environment in which front line teams can perform at their best, without fear of criticism or sanction.