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In January 1994, the US National Transportation Safety Board (NTSB) releases a safety study. Its report number is NTSB/SS-94/01. It covers 37 major accidents involving US airlines between 1978 and 1990. In each of these cases, the flight crew had been cited as a cause or contributing factor. The board wants to know what these accidents have in common. An example of the Team Principle of Attunement.
Looking Beyond the Individual Case
Situation
Each of the 37 cases – 36 accidents and one incident – had been investigated on its own. Now the NTSB lays them side by side and looks for patterns: How experienced were the pilots? How long had they been awake? Was the flight delayed? What errors were made? And: How well did the two people in the cockpit know each other? Everyone involved was trained and certified.
Connection to the team principle
The Team Principle of Attunement says: a team becomes good when everyone knows what the others know, what they can do and what they will do next. The study examines precisely what tends to get lost in accident reports. A single report looks for the error of the day. Only by looking at the cases together can you see whether something was missing between the people.
The First Day Together
Situation
Data on crew familiarity are available for only some of the accidents. Of the 15 cases for which data exist, 73% involved a captain and first officer on their first day of flying together. Of the 16 cases with data on the flight itself, 44% even involved the pair’s very first flight together. In addition, 53% of the first officers involved were in their first year with their airline.
Connection to the team principle
When you sit next to someone for the first time, you know their qualifications but not their ways. You don’t know how they read a situation, when they hesitate or what their silence means. Caution is needed here. These are very few cases, and all of them are major accidents. What is missing is a documented baseline: how often crews fly together for the first time in normal operations anyway. Without that comparison, the clustering is a strong indication, not proof. It shows a pattern, not a cause.
The Captain Flies, the First Officer Stays Silent
Situation
In over 80% of the accidents, the captain was flying the aircraft and the first officer was monitoring. In normal operations, the two split the flying roughly evenly. The NTSB found errors in monitoring and challenging in 31 of the 37 accidents. In 17 cases, the same picture emerged: the captain makes a tactical error of judgment, and the first officer does not object. Of 51 tactical decision errors identified, 28 went unchallenged.
Connection to the team principle
This is where the cost of a lack of attunement becomes tangible. Challenging a stranger is harder than challenging someone you know – all the more so when that person outranks you and you are new to the company. If you don’t know the other person, it’s hard to judge whether their decision is a mistake or intentional. So you wait. Attunement is therefore about more than smooth routines. It is also what makes it possible for one person to spot the other’s mistake in time and speak up.
Tired, Delayed – and Strangers to Each Other
Situation
The study identifies further clusters. Half of the captains for whom data were available had been awake for more than twelve hours at the time of the accident, and half of the first officers for more than eleven. Of the accident flights with data, 55% were delayed; at the time, the usual rate was 17 to 28%.
Connection to the team principle
Lack of familiarity was not the only factor, and the study doesn’t claim it was. But fatigue and time pressure are exactly the conditions under which a team falls back on what it can do without thinking. An attuned team has a reserve to draw on at that point. A team on its first day together has none. A finding from an entirely different field fits this picture: in software projects at an Indian services company, Robert S. Huckman, Bradley R. Staats and David M. Upton found that a team’s performance is strongly related to how often its members have worked together before – how long people had simply been with the company showed no such reliable link.
Five Recommendations
Situation
On February 3, 1994, the NTSB sends five recommendations to the Federal Aviation Administration (FAA), numbered A-94-1 through A-94-5. They concern checklists, mandatory Crew Resource Management training, simulator training in realistic line-operations scenarios, the onboarding of new pilots and training on fatigue.
Connection to the team principle
An airline cannot ensure that all its pilots know each other. So the recommendations focus on where attunement can be replaced or accelerated: fixed procedures that are the same for every crew, and joint practice in working together as a crew. If two people don’t know each other, they should at least know the same procedure – and have learned that speaking up is part of the job.
Key takeaways
Key Lessons
- Treat the first day together as a risk. When you put new teams together, don’t schedule critical tasks for that day, or build in extra safeguards.
- Give new pairings fixed procedures. Standards and checklists bridge what two people don’t yet know about each other.
- Say explicitly at the outset that you expect people to challenge you – especially newcomers and those junior to you. No one challenges a stranger unprompted.
- Watch for the combination: new to the team, tired, under time pressure. Each factor on its own is routine; together they are dangerous.
- Read numbers like these honestly. A pattern drawn from a few cases is a reason to act, but not proof.
Summary
The 1994 NTSB study examines 37 major accidents and finds a striking cluster: often the captain and first officer had been flying together only since that day, and often a wrong decision went unchallenged. The case numbers are small, comparison figures from normal operations are missing, and the study does not establish causes. As a counterexample, it is nonetheless compelling. None of the pilots lacked training – what was missing was knowledge of each other.