Firing Captain Kirk

July 5, 2006 — -- Periodically, over the past several years, those of us who marshal around words and phrases for a living have taken a deep breath and decided to go ahead and dare to discuss in public the fact that the airline industry in the United States is -- every hour of every day since the fall of 2001 -- setting a new safety record no one thought possible: zero passenger deaths.

Since such a safety record is expressed in facts, it gives us a great opportunity -- some might regard it as a temptation -- to try to dazzle and impress you with statistics in telling the story, as well as the temptation to pick a pet reason why we've avoided fatal accidents for so long.

For their part, of course, the airlines refuse to talk at all about this amazing four-and-a-half-year record of perfect safety, believing that Americans are so weak-minded and timid that any reminder of mortality may drive you away from their airplanes.

Airline pilots and flight attendants, meanwhile, tend to be just plain superstitious about such things, holding the vague belief that the moment we mention a safe flight record, it will most probably end in tragedy. And, of course, to be truthful in the extreme, there is a high likelihood that, regardless of how good we've become, somewhere, somehow in the future -- and despite more than 50 million successful flights since 2001 -- there will be another accident.

If you're still reading and not calling Amtrak, good, because there's a lot more you should know about this incredible safety record, starting with the fact that it is -- absolutely no pun intended -- no accident.

Yes, it's certainly true -- as a recent article in USA Today pointed out -- that the presence of a marvelous "black box" device called an Enhanced Ground Proximity Warning System in every airliner has virtually stopped the type of accident we refer to as "Controlled Flight into Terrain," the sort of wholly avoidable tragedy where pilots make human mistakes and fly their perfectly good airplane into a ridgeline or sometimes onto flat ground.

And it's also true that several other technological advances, coupled with "lessons learned" changes in procedures, have rid us of other human-caused accidents, while the type of mishap due primarily to structural or mechanical malfunction has become almost dinosaur-rare.

But, as legendary radio broadcaster Paul Harvey would say, let me tell you the rest of the story, and it's a doozy!

First, I should tell you about a highly successful little operation at Moffet Field in California, run by NASA and called the Aviation Safety Reporting System. Pilots and mechanics and anyone with safety information to share can and do send in detailed reports of near-misses and almost-disasters, as well as narratives of what went wrong -- or what might go wrong in the future because of a perceived problem -- and the ASRS team investigates the report, strips the reporter's name from it, and adds the details to a growing safety hazard database.

There are great advantages, especially to a crewmember, for filling out the ubiquitous ASRS reports, not the least of which is a limited immunity from FAA "enforcement" action when the report concerns an inadvertent human mistake. But it also gives aviation professionals a way to immediately alert everyone to a problem without fear of the problem being ignored.

What the ASRS system and its reports do is give a living, breathing picture of the status of aviation safety, not as a result of airline spin doctors putting things in perspective, but from the honest and raw viewpoint of the troops on the front lines.

Incident reports fall into a wide variety of categories, and the folks who run ASRS make the most-often-seen categories available as specific datasets. These categories -- such as Altitude Deviations, Air Traffic Controller Reports, Checklist Incidents, Controlled Flight Into Terrain incidents -- and many more can be viewed at this Website.

Each grouping, when studied, gives a snapshot of the type of close calls and mistakes that are occurring out there every day -- mistakes that fortunately have yet to metastasize into a major accident.

But wait a minute. If dangerous mistakes are happening every day, why are we so safe?

Two reasons. First, the fact that aviators and aviation safety professionals work hard to read, study, and apply lessons learned immediately. Second, because we have learned to work as a true team in the cockpit and beyond.

I promised you the behind-the-scenes revelation on why we've become so safe, and here it is: Tucked away in that ASRS dataset list is a category called "CRM Issues" -- reports providing clear evidence that the primary reason we've racked up 4 1/2 years without a passenger death in the U.S. is a thing called Crew Resource Management.

In a nutshell, CRM is an absolute reversal of the iconoclastic cockpit culture we used to have up to the mid 1980's, and if CRM had been imposed on "Star Trek's" Captain Kirk, it would have cost him his command.

Kirk, just like most airline pilots before the mid-80's (me included), was taught to be omnipotent and infallible and in need of no one's advice, let alone that coming from a subordinate crewmember. To be a Captain Kirk, you had to be ready, willing, and able to assume that you not only could be perfect -- despite being human -- but that you were, in fact, perfect. Therefore, the act of shutting up a subordinate by waving a finger in his or her face with the angry retort, "When I want your !&@*$% advice, I'll ASK for it!" was just part of the paradigm. Captains were God, and everyone else followed respectfully -- or else.

CRM changed all that. The principles grew from a series of catastrophic crashes in the seventies in which the major causal factors revolved around one imperfect human mind controlling every decision in a culture that discouraged comment or correction.

One of those disasters occurred in the Canary Islands on March 27, 1977, when the chief pilot of one of the world's best airlines (KLM) made an unchallenged mistake and started his takeoff into fog without takeoff clearance. The resulting collision between two 747's killed 583.

CRM training -- a pioneering effort to change the Captain Kirk syndrome and begun bravely by United Airlines in 1983 -- essentially overhauled the cockpit culture. It told captains that if they weren't willing and able to encourage and maintain constant, non-confrontational input from all of their subordinate crewmembers, they could go fly for someone else.

At the same time, CRM training taught subordinate copilots and flight engineers and, later, flight attendants that they were co-equally responsible for the safety of everyone aboard, and that it was no less than their job to speak up and keep on speaking up if they saw a safety problem or an unsafe decision, especially if the captain was refusing to reconsider.

This was a huge cultural alteration, and like all cultural changes in a well-established human system, it didn't "take" without tremendous effort and many years of firm, determined training and the absolute unwavering support of everyone from the CEO through the training captains on down.

Today, however, there are no captains out there who can expect to keep their command very long by ignoring their junior officers because the culture has changed utterly to one of true teamwork, featuring multiple minds helping with each decision and double-checking against inevitable human error.

Captains still make the final decisions, but only with the input and counsel of their highly trained subordinates.

And the proof? Well, that new culture is what you see reflected over and over again in today's ASRS narratives. Fifteen years ago, the ASRS folks were receiving an increasing number of surprising narratives telling how CRM had saved the day. Today, it's the deviations from the CRM norm that are rare enough to merit their own category in the ASRS system.

In other words, what you see when you read those reports -- and please do, anyone can go through them -- are crewmembers self-assessing the occasional failure to adhere to principles of open and timely teamwork.

Yes, some of our black boxes have made a huge difference. But the silent revolution in the commercial cockpits -- taking us from the days of Captain Kirk's false omnipotence to today's atmosphere of teamwork and open communication based on the recognition that no one is perfect -- is the primary reason we've achieved four-and-a-half years of perfect safety.

What's more, those same principles -- now being applied to medical practice nationwide -- will eventually have the same effect on human error in healthcare. In fact, the principles of CRM work spectacularly in any human endeavor from school teaching and nuclear power plant running to the operation of your average newsroom.

As individuals, we can never be perfect, but as teammates, expecting always to compensate as a team for individual human error, we do achieve near perfection.