There are two temptations here:
- If a mistake has been made, we look for those who are guilty and punish them
- If we are successful, we are pleased and reward those responsible
In both cases we do not take advantage of the experience. We learn nothing. The process of learning, however, is an essential prerequisite for improvement.
There is one group of professionals who have been learning on a very intensive level over the last 20 to 30 years: pilots. Crash investigations have shown that over two thirds of accidents can be attributed to human error. Errors in aviation lead to disasters which invariably generate a high level of media attention due to the potential scale of loss of life. Such accidents often develop from a chain of individual errors and unfavourable situations. Fortunately, individual errors are usually spotted and corrected at an early stage, stopping the chain of events in its tracks.
It is precisely this aspect that especially interests me. Why and how do certain crews manage to successfully master situations that are virtually hopeless, while others allow the chain of errors to take their course, gradually inching towards a catastrophe? What can we learn from aviation with regard to managing our company?
Jan U. Hagen has explored this question in detail and has written a book that is well worth reading (Hagen, Jan U., Fatale Fehler, Springer-Verlag, 2013). In his book he describes a concept that systematically improves how individuals work together in the cockpit. Over the years, the Crew Resource Management (CRM) approach has fundamentally changed the working culture in the cockpit. The hierarchical distance between the captain and the other crewmembers has changed so much that errors can be discussed both from the top down as well as from the bottom up. Especially in crisis situations, this new error management culture involves a far more intensive level of communication and a more effective way of working together. This allows a much wider knowledge base to be taken into account when dealing with such situations. The crew sees itself as a team rather than as representatives of individual interests.
It really impresses me to see how the aviation industry has consistently learned from mistakes and disasters. I am certain that we can learn a great deal from this example. As a company, it is so important for us to be open to learning from others.
