On March 21, 1977, Captain Jacob Van Zanten was the poster boy for all that was good in airline flying. Captain Van Zanten was the Chief Pilot for KLM, and had over 30 years of experience. He was known as the "go to" guy for all aviation matters for his airline. He was the face of KLM airlines.
On this particular day, Captain Van Zanten expertly guided his B-747 into position for takeoff on a small island in the Azores known as Tenerife. The aircraft was superbly maintained, the flight crew was highly qualified and Air-Traffic Control was directing the aircraft. Although the airport was shrouded in fog, the pending takeoff should have been no different than thousands of others Captain Van Zanten had performed over the years. Unfortunately, through a series of human errors, Captain Van Zanten could not see another 747 that was in front of him, hidden by fog. Despite doubts by his first and second officer that the Pan Am 747 was clear of the runway, Captain Van Zanten pushed the throttles forward and began his takeoff roll. Within seconds, he saw his mistake, and he made a valiant attempt to take off. Collision was unavoidable and the end result was the death of 583 passengers, the greatest aviation disaster in history. Despite all the increases in training, technology and experience, airlines were faced with the same staggering statistic: up to 80% of all accidents were caused by human error, or more succinctly, pilot error. What the airlines learned is that rarely does an aircraft crash because of one error. It is usually a series of seemingly minor unrelated errors that spell disaster.
In an attempt to reduce this statistic, airlines adopted a new philosophy of training called "Crew Resource Management" (CRM). This training focuses on team-training skills and communication behaviors. The training no longer regards the captain of the airliner as an infallible, all-knowing being. It recognizes that the only course to safety was to reduce error and manage risks as a team and through procedures and checklists. Those of you that routinely fly are familiar with the cabin announcement of "flight attendants prepare for takeoff and cross check." This is a direct result of CRM training. All crew members are assigned to check each other in order to catch small errors before they become big errors. The results were remarkable; aviation units that adopted this training saw dramatic results. Military transport squadrons reduced accidents by 52%, U.S. Navy Intruder squadrons reduced accidents by 81%, and all U.S. airlines combined reduced their accident rate to exceed the coveted "Six Sigma" standard used by business and industry as nearly perfect reliability.
Many industries have taken notice of this remarkable success, including health care and the fire service. They have recognized that their own team settings can benefit from Crew Resource Management training and are actively developing, researching and implementing this training.
What, if anything, can the law enforcement profession learn from Crew Resource Management training? According to the National Law Enforcement Memorial web site, there are an average of 163 line-of-duty deaths per year. Despite all our advances in training, equipment and technology, we are losing far too many officers. Can Crew Resource Management be another tool to drive down this heartbreaking statistic?
If the initial reports from health care and the fire service are any indication, the answer is "yes." In those medical facilities that have embraced CRM, there has been reported a tenfold reduction in wrong site surgeries as well as very significant reductions in other patient care errors. CRM can impact police work. The training can be implemented fairly quickly and does not require a large output of money or resources. Instructors can be taught to integrate these concepts into all their training, and the entire Crew Resource Management concept can be up and running fairly quickly. CRM can be taught to two-person patrol teams as well as larger tactical teams. In fact, the concepts apply to any team that is working in a highly charged and fast paced environment. Police work certainly qualifies!
If we use the ten year average of 163 line-of-duty deaths and reduce that by only 20%, we will have saved 320 officers. If we approach the success of the airlines or military flight squadrons and reduce line-of-duty deaths by 80%, we would save the lives of almost 1300 officers! Let us do even better; we should beat the airlines and strive for better success. Crew Resource Management training just might be the start for that noble goal.
