Changing Cockpit Culture: Why We Fired Capt. Kirk
March 29, 2005 — -- How fast would you turn around and get off a big commercial jetliner if there was no co-pilot and the captain was planning to fly alone? Even though big airliners can be easily flown by one pilot, most of us would beat feet back to the terminal simply because the concept feels so unsettling.
Yet before the early 1980s, most airline flights worldwide might as well have had only one pilot because our so-called cockpit culture dictated that the captain was an absolute commander and everyone else followed. In fact, we were all taught to be like Capt. James T. Kirk of the starship Enterprise, a commander who needed no advice from anyone, least of all his co-pilot.
You probably remember Capt. Kirk from the original 1960s "Star Trek" series, which you still see in reruns. Kirk had all the answers to all the questions all the time and expected himself to be error-free. But he had a dangerous professional flaw: Kirk, like all of us airline pilots, was a carbon-based human virtually incapable of being perfect -- yet he was the very model of the traditional airline captain.
When Subordinates Won't Speak Up
But wait a minute: Any system that routinely expects imperfect humans to perform without making mistakes is dangerously delusional. Mistakes and errors will still be made, regardless of our best efforts. If we don't build our safety systems to expect them and safely absorb them, a single error can metastasize like a cancer into a major accident. And clearly, an airline captain whose subordinate crew members are unable or unwilling to point out his mistakes is flying the plane by himself.
Throughout the '60s and '70s there was a steady drumbeat of airline crashes in which a subordinate pilot had the very information that would have prevented disaster but couldn't pass it on to the all-knowing captain.
The absolute worst example of this was the runway collision of a KLM 747 with a Pan American 747 in the Canary Islands in 1977, which killed 582 people. At different times, both the co-pilot and flight engineer on the KLM flight deck knew something was very wrong, but the command culture prevented them from telling the captain -- the airline's chief pilot and one of the best and brightest -- that he was making a horrific mistake and beginning a takeoff without a clearance.
This was the lightning bolt of realization that forced us to change our culture. In short, we've fired Capt. Kirk and reversed the definition of how a good captain runs his or her cockpit by using a discipline called CRM -- Crew Resource Management. Now captains lead by constantly soliciting and using the intellect and suggestions of ALL subordinate crew members, as a team.
Today, in other words, we don't tolerate airline captains unwilling to listen to their co-pilots or utilize their expertise. And, we also no longer tolerate subordinates who are reluctant or afraid to speak up.
And that is the major reason it's been an amazing 3 ½ years since the last major airline accident in the United States. Yes, we've improved maintenance and training and added some black boxes to prevent airliners from flying into the ground, and those things have contributed to airline safety. But the major reason that flying the airlines is now statistically safer than walking is that two or more minds are clearly better than one, especially when it comes to safely absorbing and cancelling the mistakes that even the best of professional pilots can make.
John J. Nance, ABC News' aviation analyst, is a veteran 13,000-flight-hour airline captain, a former U.S. Air Force pilot and a lieutenant colonel in the Air Force Reserves. He is also a New York Times best-selling author of 17 books, a licensed attorney, a professional speaker, and a founding board member of the National Patient Safety Foundation. A native Texan, he now lives in Tacoma, Wash.