Human Factors in Aviation
The aviation industry adopted Crew Resource Management (CRM) to prevent errors through psychological safety, clear communication, and awareness of cognitive biases, even among experienced crew. This mindset shift applies broadly to any high-stakes environment where team coordination and human factors are critical.
THE IDEA
Human Factors in Aviation
A former airline captain explains how, even in the world of aviation, the up‐take of Human Factors thinking took time, support and encouragement, and a shift in mindset:
‘There were a series of air crashes, such as US 173, which told us how much the human element mattered.[24] For example, in that case, everyone in the cockpit focused on one problem for the captain, which meant that another factor, the amount of fuel left in the tanks, was overlooked.
As a result, the discipline of “crew resource management” started to become front and centre of what we needed to push safety to the next level. But I can't stress enough how much of a mindset change this entailed, even among flight crew whose lives depended on learning about and implementing a way of working that said, “anyone can make a mistake, so we need to guard against this”. And the tricky bit was recognising that it applied to the most experienced, senior crew, not just the less experienced crew. Some of these older crew members in the early days had thousands of hours of flying experience and had not been involved in a crash and, therefore, thought they knew best.
The traps we needed to overcome included getting rid of the assumption that an experienced crew member knew the correct answer. You only need to read the transcripts of some air crashes where more junior staff are timidly raising their concerns with a domineering captain to realise how serious this problem is. So, you learn to verbalise your thoughts and proactively invite other crew members to test or correct your understanding. I like the Captain Kirk model from Star Trek; he was clearly the leader, but he would often ask the other senior crew members for advice.
Likewise, you learn that even the most obvious exchange of information to a person sitting next to you can go wrong. In pilot training and in‐flight simulators, you learn about the myriad ways confirmation bias, anchoring, availability bias, etc., can taint what appears to be the most “no‐brainer” conversations and assessments of where you are and what you should do. Nowadays, even when travelling with my wife in our car, I have retained a “double‐check” approach to programming a GPS or taking down a phone number!
Likewise, when it comes to communicating concerns, pilot training teaches you the importance of early communication and a clear escalation approach with colleagues, from questions, to offering hints and tips, to making suggestions, all the way to giving instructions or taking over control. I sense this sort of discipline in communicating with others would add value in other environments. For example, in a surgical context, I understand it's still not commonplace for surgeons to ask for, and to be content with, feedback from the nursing staff.
The other thing that you understand very clearly in aviation is the bandwidth problem. Crew, and people in general, can take on only so much information and perform only so many tasks in close succession. All too often, when I “swap notes” with those who work outside of aviation, I can see an unrealistic sense of what bandwidth people have. In aviation, you are constantly thinking about workloads and distractions and are hypervigilant about how these factors might get you into trouble.’
I trust some readers will recognise that these insights have a much broader application outside the cockpit. In principle, there should be the opportunity to speak freely (with psychological safety) about the risks of a project, staff workloads or someone who is bullying or misbehaving. However, egos, impatience and fear of what the boss might say can all undermine having the right conversation.
There are many areas you can explore to better understand Human Factors, behavioural risks, etc., and see what role they play in disasters or setbacks.[25] However, for this overview, I have decided to focus on three considerations that are often present when I am involved in RCA work:
- The presence of individual psychological factors (including assumptions and biases).
- Group dynamics that impact team meetings, committees, steering groups and boards.
- Organisational politics.
When to use it
Cockpit crew coordination where junior members need to speak up about potential errors.
Surgical teams where nurses should feel empowered to correct a surgeon’s mistake.
Business meetings where team members are encouraged to test assumptions and voice concerns about project risks.
Project management when assessing workload and capacity, avoiding the bandwidth fallacy.
FROM THEORY TO EVERYDAY LIFE
In practice
US 173 Crash – Tunnel Vision on One Problem
In this aviation accident, the entire cockpit crew focused on a single issue (a landing gear problem) for the captain, and overlooked the fuel level, leading to fuel exhaustion. Fixation and lack of communication can cause catastrophic oversight.
Captain Kirk Model of Leadership
The captain likens effective crew resource management to Captain Kirk from Star Trek: he is clearly the leader but actively solicits advice from other senior crew members. This encourages input from all team members and reduces the risk of a domineering leader shutting down critical information.
Double-Check Approach in Daily Life
After training, the captain applied the same double-check discipline to everyday tasks like programming a GPS or recording a phone number, recognizing that even simple exchanges can be tainted by biases.
Surgical Context – Nurse Feedback
The text notes that in surgical settings, it is still uncommon for surgeons to actively seek and accept feedback from nursing staff, highlighting a failure of psychological safety and team communication.
A MOMENT TO REFLECT
Put it to work.
In your workplace, do you actively invite input from junior or less experienced team members, or do hierarchies suppress that voice?
When you are in a high-pressure situation, how can you deliberately check for confirmation bias or anchoring in your own thinking?
How can you create a culture where it is safe to ask questions, offer hints, or even challenge a decision without fear of negative consequences?
Often confused with
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)