Team working problems contributing to accidents

Good teamwork is particularly important to reduce error and maintain safety in the workplace. There are many documented cases where teamwork failures have contributed to accidents, especially in aviation (see Wiener et al., 1993), and, as discussed earlier, this was the trigger for the development of crew resource management and other non-technical skills training. The example of good team working shown in Box 5.1 can be contrasted with the failure of team working in a naval incident described in Box 5.2 below.

Box 5.2 Failure in team working on board a nuclear submarine

On the afternoon of 9 September 2001, the USS Greeneville (a fast-attack nuclear submarine) collided with the Ehime Maru (a Japanese fishing and training vessel) off the coast of oahu, Hawaii. At the time of the collision the Greeneville was performing an emergency surfacing manoeuvre for a group of civilian guests on board the submarine. As the submarine rose to the surface, it struck the Ehime Maru, causing the ship to sink in less than 10 minutes. of the 35 Japanese crew, instructors and students, 26 were rescued and 9 perished.

The National Transportation Safety Board (2005) determined that the probable cause of the collision was the Commanding Officer’s overly directive style, and a failure in team working and communication of key watchstanders. An outline of the main failures in non-technical skills that led to the accident are described below:

  • • As the submarine was behind schedule, the Commanding Officer (CO) rushed his crew, resulting in the truncation of recommended steps for safe operation.
  • • Both the sonar supervisor and the fire control technician of the watch made assumptions about sonar contacts in the area, which later resulted in their providing incomplete and erroneous information to the Co.
  • • As opposed to overseeing the inexperienced Officer of the Deck-2 (OOD-2) by having him direct vessel movements that the Co could verify as being correct, the Co essentially took over the conn (directing the steering of the submarine) without acknowledging that he was doing so. He ordered specific depths and turns, which the OOD-2 repeated to the diving officer and the helmsman.
  • • Before the Greeneville rose to periscope depth, the Co announced to the personnel in the control room that he had a ‘good feel’ for the contacts. ‘In effect, the Co’s flawed situational awareness regarding the proximity of vessels at the surface reinforced and influenced the watchstanders’ own limited situational awareness which had the effect of discouraging backup from his crew’ (p47).

The failure of the two-way communication necessary for effective bridge resource management in the Greeneville control room was further compromised by the Co’s management of, and interaction with, the visitors. The 16 civilian visitors created both physical and communication barriers for the personnel in the control room.

NTSB (2005); Roberts and Tadmore (2002).

Reviews of other high-profile accidents - Pan Am Flight 401 crash (1972), the explosion of the chemical process plant at Flixborough in England (1974), the Pan Am and KLM collision at Tenerife (1977), the Three Mile Island accident in the U SA (1979), and the USS Vincennes incident (1988) - identified three main teamwork problems (Rouse et al., 1992), namely:

Roles not clearly defined - a lack of clearly, and appropriately, delineated roles was found in all instances. For example, during the pan Am Flight 401 accident in 1972 (see Box 5.3), a troubleshooting task dominated the crew’s attention and flight control was ignored.

Box 5.3 Flight 401 incident (1972)

A Lockheed L-1011 with 176 people on board (163 passengers and 13 crew members) crashed 19 miles north-west of the Miami International airport on 29 December 1972. In total, 99 passengers and 5 crew members were fatally injured in the incident. The flight from New York to Miami was turning in to land when the crew noticed that only two of the three main landing gear lights had illuminated but the nose wheel light had not.

The NTSB (1973) attributed the crash to ‘the failure of the crew to monitor the flight instruments during the final four minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground.’ Furthermore, the report commented on the ‘preoccupation with a malfunction of the nose landing gear position indicating system [which] distracted the crew’s attention from the instruments and allowed the descent to go unnoticed.’

The crew, consisting of the captain, first officer and flight engineer, all became involved in dealing with the nose wheel light, such that no one was monitoring the plane’s flight.

  • Lack of explicit co-ordination - conflicting goals were not balanced properly in the operations team in two of the incidents listed above. A contributory cause of the release at the Three Mile Island nuclear power plant was due to the focus on the goal of protecting pumps rather than shutting down, which resulted in losing the plant. At Flixborough, the focus was on maintaining operations rather than safety, and again the result was losing the plant.
  • Miscommunication/communication - the plane crash at Tenerife is a classic example that has been used earlier to illustrate failures in non-technical skills (Box 1.1). In Box 5.4, we present another aspect of this accident to illustrate communication problems within and between teams. Although English is the international language of aviation, there can be difficulties for non-native speakers relating to accents and language differences. The lack of communication, as well as miscommunication, contributed to the collision between the two airliners.

Additional analysis of the formal records of investigations into other aircraft accidents indicated incidents where crew co-ordination failed at critical moments (Helmreich and Foushee, 1993). For example:

  • • A co-pilot, concerned that take-off thrust was not properly set during a departure in a snow storm, failed to get the attention of the captain, resulting in the aircraft stalling and crashing into the Potomac River in Washington, D.C. (see Box 4.5).
  • • A crew, distracted by non-operational communications, failed to complete checklists and crashed on take-off because the flaps were not extended.
  • • A breakdown in communications between a captain, co-pilot and air traffic control regarding fuel state led to a crash following complete fuel exhaustion.

Box 5.4 Tenerife disaster (1977)

The following is the final section of the transcripts from the cockpit voice recorder of the KLM and Pan Am Boeing 747 collision in Tenerife (27 March 1977) (taken from ICAO Circular 153-AN/56 (pp22-68)):


KLM - KLM captain (KLM 2 - co-pilot; KLM 3 - engineer) APP - Tenerife tower

RDO - Pan Am radio communications (co-pilot)


...four eight zero five is now ready for take-off ... uh and we’re waiting for our ATC clearance


KLM eight seven zero five uh you are cleared to the Papa Beacon climb to and maintain flight level nine zero right turn after take-off proceed with heading zero four zero until intercepting the three two five radial from Las Palmas VOR.


Ah roger, sir, we’re cleared to the Papa Beacon flight level nine zero, right turn out zero four zero until intercepting the three two five and we’re now (at take-off).

KLM 2:

We gaan. [We’re going]




No... eh.


Stand by for take-off, I will call you.


And we’re still taxiing down the runway, the clipper one seven three six

RDO and APP communications caused a shrill noise in KLM cockpit - messages not heard by KLM crew.


Roger alpha one seven three six report when runway clear


OK, we’ll report when we’re clear


Thank you

KLM 3:

Is hij er niet af dan? [Is he not clear then?]


Wat zeg je? [What do you say?]

KLM 2:


KLM 3:

Is hij er niet af, die Pan American? [Is he not clear that Pan American?]


Jawel. [Oh yes. - emphatic]

Pan Am captain sees landing lights of KLM Boeing at approximately 700m. The two planes collide.

While the aviation accidents are particularly well documented, studies of adverse events in health care (Leonard et al., 2004; Reader et al., 2006; Vincent, 2006) and other industries (Turner and parker, 2004; Glendon et al., 2006) have frequently demonstrated failures relating to communication and co-ordination in teams with status differences and role confusion as key contributing factors.

Team working problems can also arise due to the level of experience within a particular team, i.e. how long and how effectively the team has been working together, irrespective of any individual team member’s experience. Members of inexperienced teams show more of a tendency to focus on their own individual tasks and the overall goals. Confusion can also arise in inexperienced teams about roles and responsibilities. Some team members may not fully assume their tasks, work less hard when in the team setting than if they were working alone, and may be insensitive to the needs of other team members, resulting in loss of effort. on the other hand, members of experienced teams who are accustomed to working together focus on the overall status of the team, identify themselves with the whole team, appreciate that team members may need to compensate for others, ask for help and support each other to achieve team goals (Klein, 1998). Related to the issue of experience, are the changes that occur at different stages in a team’s lifespan.

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