This is the story of United Flight #173, Portland, Oregon. It is a bit of an old story, but still important
This flight was preparing to land after an uneventful flight. But as they neared the airport the landing gear indicator light malfunctions. This means that the crew is not certain whether the landing gear is truly down. To problem solve, the plane flies about 10 miles out from the airport and begin to circle. The pilot attempts to determine if the landing gear is down. However, the Pilot becomes completely ‘fixated’ on the problem to the exclusion of ‘big picture’. The Co-pilot is aware that they are running out of fuel and attempts a few weak “hints” that the fuel is critically low, but the pilot never responds or acknowledges the “hints”. Ultimately, the plane runs out of fuel and crashes killing the crew and multiple passengers. The experienced crew managed to crash a perfectly functional plane.
Two key findings/themes: loss of situational awareness by a well-trained, experienced professional and failure of an equally qualified professional to assert themselves due to a culture that simple did not allow for a subordinate to more aggressively speak up in the face of impending catastrophe. These two individuals were talking, but they certainly were not communicating.
This happened in 1978. In 1981 UAL implemented the first Crew Resource Management (CRM) program. One of the elements of this first generation program was to focus not only on junior crew members speaking up; but, also those in charge moving away from overly authoritative communication and leadership styles. These changes, along with more reliable planes, have created an aviation system that is incredibly safe. The teams now effectively communicate and they do it in an assertive but respectful manner, even in the face of authority.
I think we all understand that aviation is not medical care. In fact, I think our challenges are exponentially more difficult because our teams are distributed over both space and time. We are not in a tiny cockpit with predictable flight patters and landing zones we have been too many times. Yet, there are still many concepts about communication and authority that we can amend to our purposes if we are willing.