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Does it have to be life or death before mistakes are not an option?

I spent last week at Plas Y Brenin, The National Mountain Centre in Snowdonia, for the first week of training towards the International Mountain Leader qualification.  One of the core topics was ‘responsibilities and consequences in the mountain environment’ and it was fascinating to hear the views of other instructors from a variety of backgrounds.

One of the guys, Thomas, who is qualified to take you up a 600ft, multi-pitch climb on any of Ben Nevis’ sheer rock cliffs, should the mood take you, mentioned Crew Resource Management (CRM) and how it’s being deployed in the outdoor industry.  Having heard briefly about the same subject from a doctor friend, I was keen to learn more and it has become apparent that it’s a school of thought that will soon permeate management practices across most industries.

CRM may have gained its moniker fairly recently, but its roots can be traced to the Second World War when a psychologist named Alphonse Chapanis, rather than retraining pilots, ended up requesting simple design changes to the controls of bomber aircraft to avoid human error.  As daft as it sounds, accepting some fallibility in elite pilots was a big advance in thinking.

The aviation industry really woke up to the idea of CRM in 1978, when pilots of United Airlines Flight 173 fixated on what turned out to be a non-existent problem with the landing gear for long enough to run out of fuel and crash into woodland, despite recordings clearly relating the engineer’s polite concerns over fuel.  Ten people died on a plane that had been circling an airport for nearly an hour.

In the 90’s, James Reason, a cognitive psychologist, proposed a ‘Swiss Cheese’ theory, stating accidents in large organisations are usually due to a series of poor decisions and mismanagement rather than an individual mistake, for the simple reason that one individual shouldn’t be in the position to make an error can lead to, for example, the crashing of a super tanker.  In flawed systems, the holes in the cheese just have to line up for there to be trouble.

You will not find a surgeon in the NHS who is ignorant of CRM, thanks to the crusading work of one man, Martin Bromiley.  Martin’s wife, Elaine, died in 2005 while undergoing a simple sinus operation when three senior surgeons fixated on getting a tube into her collapsed airway, rather than performing a simple tracheostomy that would have saved her life.

The investigation highlighted an environment where the surgeons’ inscrutable authority meant grave hints from nurses and myriad ominous warning signs went unnoticed and none of the junior staff ever felt confident enough to intervene by stating the obvious.

Martin, a pilot, recognised those failings as the same ones his industry dealt with long ago by introducing training, management systems and communication protocol.  In an act of supreme humanity, he did not seek to punish those responsible; rather, make the health industry safer to avoid repeat incidents.

Returning to Thomas, working in a climbing environment where human error is far more likely to lead to death than equipment failure, CRM sees him instilling the confidence to question his actions into every novice he takes climbing, in case they spot a simple error that may one day happen.

Lynn Hill, once the best female climber in the world, famously ended up in a tree, unconscious with multiple broken bones, after the knot she tied to attach herself to her rope came undone when 75ft up a climb.  The one thing a belayer always checks is their climber’s knot, but do you do that with the world’s best climber who has tied it many thousands of times?  Apparently you should and it’s these situations that CRM seeks to prevent.

227080_10150230525210973_4011309_nBack in my fairly autonomous role for the RBN, it is difficult to image a scenario where my actions, or lack thereof, could have serious consequences for anyone other than myself.

Without being wilfully rude to a sponsor, somehow going off-topic and inspiring a Rushdiesque fatwā against the organization or being rude to the Burgess brothers’ mum, careers and lives should be safe regardless.  That is not the norm for cogs in bigger machines.

Spend a few minutes browsing the business pages of a broadsheet and it will not be long before you read about huge contracts being lost, pitches failing, mass redundancies and, occasionally, catastrophic losses due to obvious errors in judgement, system failures that should never have been possible or maybe just plain arrogance.

The essence of CRM is teamwork and communication in an environment that recognises human fallibility and, crucially, that the consequences of failure outweigh and take precedence over upsetting the social hierarchy.

The hierarchy problem is the key one that CRM seeks to address, because it goes against how most organisations work.  Even the army, with their tradition of unwavering and unquestioning obedience down the chain of command, has had to embrace CRM to a degree because it can save lives, as highlighted by numerous ‘friendly fire’ incidents.

So, is CRM something you need to adopt?  In all probability, yes.

Your staff can most likely question their peers and juniors and maybe politely raise a query with their manager, but would they really risk offending a senior employee by questioning the logic of a fundamental decision?  They should, because there have been many situations in business where junior staff could have saved companies fortunes.

Maybe work backwards from what you would least wish to go wrong, rather than forwards from common errors.  It could be failure to deliver on time, a pitch to a key client shifting away from the brief in the creative process, a design flaw or pending legal liability.  The list is endless across industries, but far shorter for any one company.

Who has power or responsibility enough to make damaging decisions or outcomes for your business?

What would have to go wrong and who could flag that problem before a critical stage?

Would those people speak up?

Do they speak up now to you and your senior staff and, if not, why are they not encouraged to do so?

If they did, would they be put in their place or their input valued?

The key here is that, at times of crisis, senior staff are more likely to feel pressure and behave on instinct, whereas junior staff on the peripheries have the broad, more detached view.  So, although managers need to told to be be open to questioning, the key lies in explicitly telling staff that they are free and required to speak up if they see errors, regardless of how sensitive the timing.

The solutions will be too specific to circumstance to list, but at the root of the new NHS protocols are check lists and huddles.  Check lists provide a structured approach that can be improved over time to include historically significant factors and items, whereas huddles provide the whole team with a platform to voice concerns that may not have risen before.  Variations on those two themes alone could prove priceless to you.

A final and recent example of this, again a tragic accident, was British Midland 92, which crashed on the side of the M1 in 1989.  An engine fire warning light flashed up in the cockpit, so the captain announced that a problem with the right-hand engine meant they were going to perform an emergency landing.  Most of the passengers and cabin crew could see flames leaping from the left-hand engine, but that information was not relayed to the revered pilot and his officers.  The pilot then shut off the wrong engine, sealing the fate of 47 passengers.

I shall avoid the lazy pilot metaphor here, suffice to say the lessons from an industry that has no option but to invest everything it can in the avoidance of disasters should be taken very seriously, especially when most others industries have more to gain and less to lose.

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