One of the many hard lessons learned by the aviation industry is that distributing responsibility and challenging hierarchical authority saves lives. From examining flight recorders and listening to cockpit recordings, crash investigators know that otherwise avoidable accidents have been caused by dysfunctional relationships between airline crew. The traditional model was the captain was in absolute authority and that questioning his actions was unthinkable. This led copilots and cabin crew to keeping silents when they noticed the captain making a mistake.

There are clear dangers in leaving people to organise themselves because our natural inclination is to defer to those in authority and pass the buck to others down the line. The airline industry’s response, as Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety explains, was CRM (Crew Resource Management)

Its goal was to transform a culture in which error was defined as “weakness”—which, in turn, led to shame, blame, and punishment—into a culture of learning and teamwork. Now human errors are immediately dealt with and then evaluated for what they can teach about preventing, managing, or containing their effects. Critical to this endeavor was redefining the roles of the team leader and team members. In aviation, the captain is still the captain of the ship, but his or her focus as the team leader is on the efficient and effective management and functioning of the entire team and not simply on accomplishing the tasks of the captain and copilot. Similarly, the job of the team members is not to blindly obey orders but to inquire, contribute, advocate, and assert; in the most extreme conditions, it is also to intervene if necessary to assure the safety of the aircraft and its passengers.

As is suggested by the program’s name—Crew Resource Management—the team’s job is to utilize all resources and information available. Decisions and information are shared and consistently updated. Crews are taught how to constructively frame, negotiate, and resolve disagreements so that conflicts or problems fuel further collective and individual learning experiences. Team members are redefined not as obstacles to the captain’s authority but as crucial human resources who make flight safer and the captain’s job easier.

Under this new paradigm people are still given orders to carry out, but every team member is empowered to monitor all others, and all are given a voice in decision making. All members of the team, regardless of rank, status, or position, are authorized and even encouraged to point out to any other team member—with sufficient clarity and urgency—if he or she is making a mistake. The team works to ensure that errors are resolved and do not develop into catastrophes. [My emphasis]

Mistakes in aviation are potentially catastrophic; when we get things wrong in teaching, no one dies. But the same pressures that cause pilots to make mistakes are at work to prevent teachers and school leaders acting in the best interest of their students, and maybe causing inspection teams to making avoidable mistakes in judging schools.

I recently spent some time listening to some concerns about the inspection of Bilton School. According to Ofsted, the school is inadequate because there are “serious weaknesses in keeping pupils safe.” Judgments on safeguarding are a limiting factor in judging the school as a whole: is safeguarding is inadequate, so is the school:

Leaders have not ensured that all staff understand safeguarding procedures. On occasions, staff have waited too long to refer on concerns about pupils. Leaders provided additional training during the inspection. Some teachers do not regularly complete attendance registers as per leaders’ expectations. Therefore, leaders cannot be sure of the whereabouts of some pupils. The safeguarding team is currently lacking clear leadership. There is insufficient oversight of vulnerable pupils, which means pupils could be at risk.

Damning stuff.

The headteacher, Tim Chambers had, before the inspection, been “quietly confident” that the school would be judged as having made significant progress over the past few years. Results had increased by an average of a third of a grade and there had been improvements in behaviour and curriculum provision. Some of this is recognised in the report:

Pupils, parents and staff told us that this school has ‘improved so much’ since it became an academy. Leaders want all pupils to do their best and leave their school as well-rounded people. Leaders have introduced a new curriculum, employed new teachers and improved pupils’ behaviour. Now, lessons are usually free from disruptions and pupils get on with their work. Relationships between staff and pupils and among pupils are generally positive. Bullying is now rare, and staff deal promptly with any bullying that does occur.

Pupils have regular opportunities to discuss current topics and have debates. They talked of learning about the dangers of knife crime and drug misuse. Pupils spoke highly of whole-school events that have taken place. For example, the entire school completed a race for life event for a cancer charity and raised more than five thousand pounds.

Some subject plans are well thought out and sequenced. These help teachers to know what pupils should learn. Plans follow a logical order. Therefore, pupils systematically build up their knowledge over time. Teachers adapt plans in these subjects so that pupils with special educational needs and/or disabilities (SEND) do well. Pupils confidently use their skills and achieve well. This works well in English, for example. Here teachers focus on improving pupils’ vocabulary. Pupils then use the vocabulary from one topic and apply it in the next one.

How, you might be wondering, can school leaders work so hard at these aspects of school improvement and yet neglect the basic safety of students?

According to Chambers, the lead inspector had some particular concerns: bins were not locked; registers were not taken within the first five minutes of lessons; live safeguarding cases had not been signed off; and not all staff involved in safeguarding were able to give consistent answers about procedures when grilled which was considered to be evidence of a negative cultural attitude to pupil safety. Cambers felt that some staff panicked and “broke” under the pressure of interrogation, meaning that answers contained minor deviations that were pounced on as evidence of poor leadership. Obviously I don’t know the truth of any of this. I’m not suggesting that these things are unimportant, but it’s not necessarily clear that failure to take register within the first five minutes of a lesson endangers pupils’ safety. Chambers certainly acknowledge all the challenges and  accepts that there was clear room for improvement. He was able to address all the concerns almost immediately (for instance, all staff now have a list of safeguarding procedures printed on their  ID cards, and the bins are now kept locked) but he was concerned about the way these concerns orientated the experience of inspection. But he did point out that although systems could and should be tightened up, pupils were not actually unsafe at school, and they were able to demonstrate this.

According to Chambers, much of the inspection experience was positive. The ‘deep dives’ were fair and thorough and the inspectors made insightful and useful observations. But the lead inspector made it clear that she was in charge, that her voice was the only one that carried authority and that the other inspectors were only there for her to gather evidence to help her make her judgment. This may or may not be true, but if it is, it invites some questions about how inspections teams are composed and trained.

The principles underpinning CRM are those of ‘distributed cognition‘. What this means is that everyone in team needs to know how to do—and how to think about—their individual tasks, but they also need to be aware of how their role affects the activities of everyone else, even if those people are working out of sight at any given moment. This would require inspectors to be empowered to be thoughtful, flexible and professional, rather isolated drones enacting instructions. As things stand, inspection teams are deeply hierarchical, with the lead inspector having unquestioned authority over the inspection process. This will inevitably leads to the probability of sub-optimal decisions going unchallenged. Of course, these poor decisions don’t lead to the same horrific consequences as they do in aviation, but they still wreck careers, damage the reputation of schools and can have a negative effect on communities.

If Ofsted are serious about improving school inspection, implementing the principles of Crew Resource Management would be an easy win. Lead inspectors need to be trained to listen respectfully to contrary opinions and dissenting voices, and additional inspectors need to be trained to provide crucial challenge.

Here are my top recommendations for improving this aspect of inspection:

  1. All HMIs and OIs to receive training in the principles and importance of CRM.
  2. HMIs and lead inspectors given specific training in human fallibility and their responsibility to create a culture within their teams there everyone feels able to challenge and support judgements.
  3. OIs to receive specific training in their responsibility for providing healthy challenge. A culture of complicity and silence must be irradiated.
  4. Schools encouraged to provide feedback on the way inspections are conducted as a routine. This will not only make school leaders feel their opinions are valued, it will improve the inspection process and provide opportunities for training.
  5. Accountability for HMIs and OIs needs to reflect these priorities: for instance, inspectors should be required to give 360 degree evaluations as a regular part of the process.