Evans Incorporated

What would Sully do? Team decision making in safety-critical situations

Recovering from hazardous situations often requires a little ingenuity and some creative thinking, coupled with experience, motivation and teamwork. We all have off days when we forget the car keys, push the credit card into the “Retrieve Ticket Here” slot, or spill the milk on the kitchen floor. Human performance is variable – nobody is 100% perfect, and nobody is 100% consistent. Yet the flip-side of our failures and foibles is that we also have days when everything goes remarkably well. When we perform at our finest, miracles can happen.

Consider Flight 1549. Under the leadership of Captain “Sully” Sullenberger, the flight crew glided an Airbus A320 into the Hudson River after both engines lost almost all power following a bird strike. The cabin crew members successfully coordinated the evacuation of 150 frightened passengers, including a lap-held child, and everyone on board survived. Investigating the accident, the NTSB gave credit to the entire crew for excellent crew resource management – a term which refers to the way a team diagnoses a situation, shares information, makes decisions, and plans its response.

Crew resource management is critical in many command and control contexts. Evans has recently been working with a federal client to address crew resource management in transportation system control rooms. Although operators within the control rooms are supported by automation, human decisions and actions are necessary to ensure that the entire system operates safely. The automation system used in these control rooms was built to include significant redundancy, and to self-recover from common glitches. However, sometimes the self-recovery process leads to a system slow-down. When there is a slow-down, the expert operators have more work to do in order to maintain safety, and they also have to work closely with a team of technicians and engineers to diagnose and correct the issue.

Because teamwork is critical to success in situations like this, Evans has been working closely with their client to deliver experiential workshops that highlight the principles of crew resource management. Facilitated by human factors specialists and training experts, the workshops are attended by a wide range of personnel from different technical backgrounds, all of whom have a vital role to play in managing a slow-down. The sessions have been designed to simulate system slow-downs in a classroom environment, so that personnel can rehearse the way that they coordinate with each other. This enables the team to “step through” a slow-down, discussing how to diagnose the issue, manage the situation, and regain system capacity while maintaining safety. The sessions are highly interactive, and even include simulating the actual phone calls made to the engineers on the system helpdesk. They also include a degree of uncertainty and ambiguity, which is characteristic of slow-down events.

The workshops have received very positive feedback from participants from across all disciplines. Just a week after facilitating a workshop at one location, Evans received notification that the skills developed were used in a real slow-down situation, and helped to prevent the situation from becoming critical. Evans’ approach to working with teams responsible for operating safety-critical systems is to address all of the factors influencing team performance, not just technical skills. One person performing well is a definition of a good day. But when a group of people function well as a team to diagnose a situation, share information, make decisions, and plan a response, it really can “save the day”.

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