Communication, Decision Making, and Leadership Lessons from Right Now
My three previous posts examined case studies illustrating times when deficiencies in communication, decision making, and leadership – or some or all of these combined – prevented excellence in operations and/or screamed for overhaul in process. By the early 1980’s, the aviation industry recognized the need to place structure within its operations to stop the poor communication, flawed decision making, and lack of effective leadership.
Crew Resource Management, previously known as Cockpit Resources Management, became commonplace in aviation in the 1980s as the community extracted the difficult lessons from Eastern 401, United 173, Tenerife, and other incidents. Through improvements in process and training in communication, decision making, and leadership, aviation incidents plummeted to the point where, as mentioned in my very first blog entry, in the years between 2009 and 2025, there was only one passenger fatality in domestic commercial aviation. Before we go into the fundamental building blocks of communication, decision making, and leadership and how they contribute to making High Reliability Organizations, here are my favorite case studies in each of these areas to show how effective dedicated energy in each of these dimensions can be:
COMMUNICATION
Southwest Airlines Flight 1380 was the one passenger fatality incident between 2009 and 2025. On April 17, 2018, the flight suffered a catastrophic failure of its left engine, which resulted in significant damage to the left side of the airplane, including depressurization. If you listen to the audio in the link below, the Captain articulates the nature of the problem, succinctly requests resources for assistance, and provides continuous updates to air traffic control. Also not present on this audio, the decompression caused enough noise inside the airplane that the Captain and First Officer had to use hand signals to communicate with each other, despite being just feet apart. Here is the audio from the incident.
DECISION MAKING
USAir Flight 2998 is not an incident you have heard of. On the night December 6, 1999 in Providence, RI, a United 757 had just landed. However, it is not only dark, it is also foggy and the United crew became lost on the airfield. The impeccable decision making by the crew of USAir 2998 prevented disaster, even in the face of an air traffic controller’s certainty that what was happening was not happening. Here is the audio from the incident.
LEADERSHIP
I am including two events for leadership. The first is the “Miracle on the Hudson” because it shows excellence in all three dimensions of Communication, Decision Making, and Leadership. Of note but not in this video, the Captain consults the First Officer just before touchdown to make sure that they had not missed anything in the course of the four minutes of the incident (“got any ideas?” on the CVR at 3:20:21pm).
The second is United Airlines Flight 232. The aircraft was a McDonnell-Douglas DC-10 with 296 passengers and crew aboard on a flight between Denver and Chicago on July 19, 1989. Over central Iowa, the aircraft experienced a catastrophic failure of its tail-mounted engine which caused such extensive damage to all of the hydraulic lines of the airplane that the controls became useless for the remainder of the flight. Using differential power settings between the two wing-mounted engines, the crew managed to get the airplane back to Sioux City, IA’s Sioux Gateway Airport, despite essentially flying an uncontrollable jumbo jet. One final note: I included this clip because it shows the human side of the incident and how personal leadership can help navigate tragedy.
More to follow…
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