Certainly, the mistakes that we male and female mortals make when we have our own way might fairly raise some wonder that we’re so fond of it. – George Eliot
Flying is a dangerous business. All sorts of things can go wrong and any one of them could result in disaster. That said, it’s become a cliché that flying is the safest way to travel. No other form of transportation is as scrutinized, investigated and monitored as commercial aviation. According to research into flight safety, over the fifteen years between 1975 and 1994, the death risk per flight was one in seven million. Anytime you board a flight on a commercial airline, your chance of being in a fatal accident is one in seven million. It doesn’t matter whether you fly once every three years or every day of the year. In fact, based on this incredible safety record, if you did fly every day of your life, probability indicates that it would take you nineteen thousand years before you would succumb to a fatal accident. That’s pretty good going. In comparison, the risk of being involved in a fatal train accident is one in a million. Driving, something generally considered so safe that most adults find it relatively easy to get a license, results in 130 deaths every day and forty-seven thousand a year. You are, on average, nineteen times less likely to die on a plane than in your car.
But this wasn’t always the case. the early days of jet flight were considerably more dangerous and far too many flights ended in disaster. Something had to be done. Part of the solution was the introduction of checklists. It was acknowledged that the list of items which had to be checked before and during a flight was too onerous to be left to the memory of any one individual, no matter how expert. The checklist has also had a profoundly transformative effect on medicine and Harry Fletcher-Wood’s forthcoming book explores how we might harness this power in education. Checklists though only marked the beginning of the cultural changes which have taken place in aviation.
The medical world is also beginning to embrace the ways aviation has changed hierarchical, organisational structures. 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]
Now, of course, mistakes in aviation and medicine are potentially catastrophic; when we get things wrong in teaching, no one dies. But the same pressures that cause pilots and surgeons to make mistakes are at work to prevent teachers and school leaders acting in the best interest of their students. What if we sought to balance the ‘orders’ teachers are given with the instruction to monitor others and point out if headteachers are making mistakes? This won’t just happen. It might take a systematic overhaul of the way schools are organised and led. But if it did happen, what might be the prize?
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 teachers to be empowered to be thoughtful, flexible and professional, not isolated drones enacting instructions, as is all too often the case. My feeling is that we all say we want teachers to act like professionals, but we don’t really mean it.
Education is as hierarchical as it gets. Heads cower beneath the fiery eye of Ofsted and the DfE; teachers labour under the burden of this fear; students get taught to pass exams rather than taught the breadth and beauty offered by subject disciplines. It doesn’t have to be this way, but it won’t be easy to change because there’s so much vested interest in the status quo. The answer, my friend is, I’m fairly sure, Intelligent Accountability.
I’m just at the beginning of finding out about the ways healthcare is learning from aviation, but despite our very real differences, I feel sure we can learn some important and useful lessons from them both. My next post will explore the problems caused by our disagreements over the purposes of education and how this is at odds with other areas of public service.
In the meantime, for any school leaders wanting to see how they might do things differently, I’d recommend starting with John Tomsett’s wonderful book, Love over Fear.