On November 4, 2010, four minutes after takeoff from Changi Airport in Singapore, the number two jet engine of Qantas Airways flight QF32 exploded. On board the Airbus A380 were 440 passengers, 24 crew members in the cabin, and three captains and two copilots in the cockpit. Debris from the exploded engine hit the left wing, destroying a number of electrical and hydraulic lines. Thereafter, several essential aircraft control systems failed. Over the next harrowing two hours, the pilots flew in a holding pattern. They needed to burn enough fuel so that the plane's final weight would allow for a safe landing.
All passengers and flight crew survived.
The Australian Transport Safety Bureau's (ATSB) 2013 report on Flight QF32 shows just how difficult the situation in the cockpit actually was and how professionally the crew responded to the emergency. In the critical 20 seconds after the engine exploded, the crew received 36 aircraft monitor system alerts. Over the next 20 minutes, another 41 were recorded. It was the unanimous opinion of the ATSB that the effective cooperation of the crew in the cockpit was crucial to the plane's safe landing.
The Qantas crew's successful response to the incident was no stroke of luck, however. Crew Resource Management, first developed in 1980, is now used in civil and military aviation training worldwide. To ensure a safe flight operation, this kind of training requires two conditions and open communication is important to both:
The hierarchy on the flight deck must be flattened.
Crews must be actively integrated into the flight's workflows and decision making processes.
This team-based approach to flight is not meant to undermine the captain's role, but rather to acknowledge that controlling a modern day aircraft is beyond the skills of a single person. In an emergency, especially, everyone on the flight deck must have the right to speak up.
We argue that traditional business models who adopt this approach to decision making in high stakes situations will be more likely to succeed in their sectors. The incident described above, and how it was resolved, exemplifies why: Crises, which will inevitably arise in any field of work, demand more from us than everyday challenges. No single person can manage one alone. Collaboration and cooperation were crucial to the survival of Flight QF32, and we believe that the same ingredients can be used to help businesses overcome the most difficult obstacles and thrive.
To support this theory, we have spent the past six years studying flight crew communication. Twice a year, aircraft crews around the world are required to complete trainings in full-flight simulators. The goal of these trainings is to place people in emergency situations and give them feedback on how to best handle them. They are concluded by a thorough check-flight within the simulator - the sole purpose being to test the crew. Pilots must pass this test to keep their license for another six months.
In the first part of our study, we observed and recorded 11 flight crews of a major European airline participating in these sessions. In the second part of our study, we conducted interviews with a total of 61 flight crew members (pilots as well as non-pilots) in the air force. Our goal was to reveal the importance of team-driven decision making during emergencies, show that teams (not leaders) make the difference between success and failure, and identify the aviation training practices that can be best adapted for and used in the business world.
In our first study, we collaborated with organizational scholars Mary Waller and Seth Kaplan to identify the benefits of Crew Resource Management rules and practices on team performance in critical situations. Over a period of 18 months, we examined how pilots and copilots interacted in the cockpit during simulator trainings, and in turn, how that interaction affected the performance of the crew as a whole. One of the simulation scenarios involved airspeed sensor failure; the other involved an unexpected loss in cabin pressure. For both, the simulator crews first had to deal with the immediate emergency and then safely complete the flight with a damaged aircraft.
Resolving the immediate emergency was arguably the easier half the challenge. Crew members did not really have to "think on their feet" because the process was a standard one. They recited a series of memory items - actions all crews are required to take in emergency situations - and then select the proper checklist from the Quick Reference Handbook to guide them through the next steps. During this phase we observed no variations between the crews as all followed the correct procedures.
However, when it came to safely landing the aircraft, our observations varied significantly. The captain's style of communication had a major impact on crew performance in two major ways. First, crews performed consistently better under intense time pressure when the copilot was included in the decision making process than when the captain analyzed the problem alone and simply gave orders. Second, captains who asked open-ended questions - "How do you assess the situation?"; "What options do you see?"; "What do you suggest?" - came up with better solutions than captains who asked simple yes or no questions. By contrast, the latter method resulted in the copilot affirming the captain's decision and proved worthless to problem evaluation and solving.
The takeaway we gathered here is that involving colleagues as equal decision partners by asking them questions - a form of leadership that organizational development scholar Ed Schein terms "humble inquiry" - taps into the other person's expertise and aids constructive, factual information exchange. These questions are not simply for the sake of participation, but rather to gather information, opinions, and proposals for action. Teams who continuously exchanged information, analyzed the facts, evaluated options, made decisions, implemented them, and then reviewed what they had implemented, were the most successful in safely completing their flight simulations.
Based on the results of the first study, we wanted to explore to what extent captains or commanders were aware of the benefits of using inquiry. To figure this out, we conducted another study examining the efficacy of Crew Resource Management training within the German and Israeli air forces. Unlike civil aviation, military pilots operate in unstable and volatile situations, and are more likely to face exceptional circumstances, particularly in war zones. We interviewed commanders, copilots, weapons system officers, and technical loadmasters to learn how they work together. Almost all respondents, both in Israel and in Germany, emphasized that cross-hierarchy cooperation was important.
More than 80% of respondents underlined the need for speaking up - that is, the need for subordinate crew members to express their opinions and ideas openly. "If you speak first, your copilot will not contradict you," stated one of the Israeli commanders. "I always ask my copilot for his opinion first. I do not want him to accept my view uncritically, especially if I am wrong."
A number of pilots we interviewed also observed that, in all critical situations, even the most experienced pilot may overlook something, act too hastily, or lose focus. Collaboration, thus, is vital to safety. "I invite [my copilot's] opinion," stated one of the Israeli commanders. "I say, 'Monitor me, notice if I miss anything.' If something is unsafe, I expect him to intervene and I will listen. I tell the copilot that the worst that can happen is me telling him that we are not going to take his suggestion at this time."
This invitation is important because, notably, many of the copilots we spoke with in both the German and Israeli forces stated that they will not speak up without an invite in situations that do not precipitate a crisis - even though they have been taught explicitly to speak up as a part of their training. "If [the commander] asks me my opinion because he's interested in it, then I answer him," said one Israeli copilot. "But if he doesn't ask me, I won't throw it in. In my opinion, the commander is in control of the situation."
However, it is not uncommon for seemingly non-critical decisions to lead to more serious outcomes. This is why open questions between crew members are needed to draw a wider range of solutions to problems - whether or not those problems are considered emergencies. Doing so helps crews go beyond what is merely feasible to produce more ideal outcomes - that is, not just a smooth landing but a smooth landing at the right airport with the right personnel, at the right time.
In summary, our second study confirmed what we had found in the first - open questions are vital to effective communication in high stake situations. But we also learned something new: Open questions are vital in all decision making processes as a means to come up with the best solutions and also as preventative measures against potentially dangerous or imperfect outcomes.
Through both studies, we were able to gather insights that ultimately support our idea that aviation's Crew Resource Management concept can be easily applied to businesses. Leaders simply have to use their teams as active resources.
People in positions of power need to make sure that the hierarchy of decision makers on their teams does not become so steep that workers in junior positions are afraid to speak up. (We realize that it's unrealistic to expect all teams to take on an outright flat structure.) In addition, we believe that to successfully apply these principles, leaders must make a concerted effort to encourage their employees to be assertive and speak up by asking open-ended questions before posing solutions, even (and specifically) in high stakes or urgent situations. When people are under pressure, it's not uncommon for them to shut down and grow quiet as opposed to being proactive. This is why inquiry is such a valuable tool for gathering information.
It is important to note that there can be exceptions, though. Inquiry is not always a silver bullet - as can be seen by the two recent Boeing 737 MAX 8 accidents. The recently published final accident report of the Lion Air crash of 2018 identified a large number of contributing factors. Apart from the widely covered technical problems of the MCAS system, the report documents pilot skill deficiencies on the part of the copilot. Therefore, the captain was lacking a crucial resource in a critical situation.
The Boeing MAX 8 case may hold a lesson for management as well. It was recently reported that Boeing's test pilots had internally discussed concerns about the MCAS system back in 2016. We do not yet know if Boeing's management was aware of these concerns, but we theorize that inquiry could have been a preventative measure in this case. Had management asked the pilots for feedback earlier on, the information regarding the system would have been pushed upward and allowed management to initiate a review of the system prior to the accident.
As we saw in our studies, it's important for those in positions of power to recognize that they do not lose authority when they ask questions or admit that they do not know everything. Leaders who ask questions create teams capable of handling the complexities of any business task, whether critical or non-critical. Researcher Amy Fraher, a retired US Navy commander and former commercial and military pilot, calls this type of leader the "creative problem solver." We would go a step further and describe them as a "collegiate and creative problem solver," someone who knows the issues and seeks out the team's opinion. We believe businesses that invest in creating a framework that emphasizes leading with questions, and one that trains and retains leaders with this skill, will be capable of achieving operational excellence.
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