Contents
On December 28, 1978, a United Airlines DC-8 circles for about an hour southeast of Portland, Oregon. There are 189 people on board. The aircraft is airworthy, and the captain has more than 27,600 flight hours of experience. Even so, the flight ends in a residential area. What happens next is a textbook case of the Team Principle of Investment: what you invest in a team pays off – with a delay, and with interest.
A Light Stays Dark
Situation
Flight 173 has come from New York and is on its way to Portland via Denver. In the cockpit are Captain Malburn McBroom, 52, First Officer Roderick Beebe and Flight Engineer Forrest Mendenhall. When the landing gear is lowered on approach, the aircraft jolts and yaws. The green indicator light for the gear stays off. It later turns out that a corroded part in the right main gear was the cause. The gear was in fact locked down; only a damaged switch prevented the indication.
Connection to the team principle
This cockpit does not lack skill. Each of the three is well trained in his own right. Until then, aviation had invested mainly in individual pilots and in technology. Almost nothing had been invested in how the three worked together.
An Hour in a Holding Pattern
Situation
The crew enters a holding pattern to work out the problem and prepare the cabin for a possible emergency landing. On departure from Denver there were about 46,700 pounds of fuel on board, more than the route required. But the holding pattern drags on. First, two engines fail for lack of fuel; then, on final approach, the rest. The aircraft crashes into a wooded residential area about six nautical miles short of the airport. Ten people die: eight passengers and two crew members, including the flight engineer.
Connection to the team principle
The National Transportation Safety Board (NTSB) identified the cause as the captain’s failure to monitor the fuel and to respond to warnings. But it also explicitly pointed to the crew’s interaction: the other two either did not fully grasp the situation or did not communicate their concern effectively. So the knowledge was there in the cockpit. It just never reached the person making the decisions. That is not one person’s failure but a gap in the team.
The Industry Invests
Situation
The NTSB recommends a new kind of training: participative management for captains and assertiveness training for the rest of the crew. As early as 1979, NASA holds a workshop on the subject; NASA psychologist John Lauber coins the term that later becomes “Crew Resource Management,” or CRM. Two years later, in 1981, United becomes the first US airline to launch a comprehensive CRM program. In 1990 the Federal Aviation Administration (FAA) introduces a program that integrates CRM into crews’ technical training.
Connection to the team principle
This investment does not pay for itself right away. It costs training days and simulator hours, and it requires captains to understand their role differently. At the outset there is no proof that it is worth it. More than two years pass between the accident and the first full program, and more than ten years before CRM is built into crew training.
The Return Comes Later – and Elsewhere
Situation
In July 1989, after a severe technical failure, the crew of United Flight 232 manages an emergency landing that many people survive. Captain Al Haynes later explicitly credits CRM training. Today CRM training is mandatory for airline pilots under the FAA and the European agency EASA. Medicine, firefighting, shipping and rail have adopted the concept.
Connection to the team principle
Here the delay and the interest become visible. The return comes years after the deposit, and it shows up in fields nobody had in mind in 1978. What began as a response to an accident has become a standard for teams in which mistakes cost lives.
What the Research Says
Situation
In 1999 Robert L. Helmreich, Ashleigh C. Merritt and John A. Wilhelm traced the evolution of CRM since 1981. Their finding: training with simulator exercises and repetition changes behavior. Without refresher training, however, pilots’ acceptance declines again over the years, and a small minority rejects CRM. In 2006 Eduardo Salas, Katherine A. Wilson, C. Shawn Burke and Dennis C. Wightman analyzed a total of 28 CRM evaluations from various industries. Participants’ reactions were positive, and there was evidence of learning and changed behavior, though not in every study. A safety effect at the level of entire organizations could not be established.
Connection to the team principle
This is an important qualification. There is evidence of an effect on behavior and learning, albeit mixed. That CRM has reduced accident rates is plausible but not rigorously proven. And there is no automatic compound interest: if you pay in once and then stop, you will watch the balance shrink. Investing in a team is a standing order, not a one-off payment.
Key takeaways
Key Lessons
- Invest in how people work together, not just in individual skills. Three good professionals do not yet make a good team.
- Practice with your team how to voice a concern so that it gets through. And as the leader, practice really hearing it.
- Don’t wait for the damage. Aviation invested after a disaster; you can do it beforehand.
- Build in refreshers. One-off training fades.
- Don’t expect the return in the same quarter. First measure whether behavior changes, not whether the metrics go up.
Summary
Flight 173 crashed even though both the aircraft and the crew were capable of landing safely. The accident investigators found that the way the cockpit crew worked together was also part of the cause. The industry learned the lesson and invested in something that hardly anyone had trained until then: how crew members talk to one another and make decisions. The return came years later and today reaches all the way into operating rooms and emergency dispatch centers. Research supports an effect on learning and behavior – and warns that this investment has to be renewed.