I listened to a discussion about the roles and responsibilities of ship's captains. The Titanic and her captain, Edward J. Smith, were presented as an example of "doing the right thing." After studying CRM and AMRM for years, I think he did a terribly wrong thing, but he had help.
I discuss Captain Smith and the Titanic during presentations on the pressures we face in HEMS. From the accident report, " Mr. Ismay (the owners representative) occasionally accompanied his ships on their maiden voyages, and the Titanic was one of them. During the voyage, Ismay talked with chief engineer Joseph Bell and/or captain Edward Smith about a possible test of speed if time permitted..."
I believe what happened was Mr. Ismay pressured Captain Smith to run full speed all the way (including at night) in order to set a record or at least make a splash in the media. The ship's construction was over-budget and took longer than expected, and the owners were anxious to prove the ship was a winner.
This is a classic case of pressure from management to get a result that may not be consistent with safety. In our case, an excessive emphasis on flight volume might well lead pilots to accept a flight when they shouldn't. Sometimes the pressure comes from within the person, with no help from anyone else. It has happened in HEMS more than once.
Captain Smith had a reputation as being "quietly flamboyant" and "a millionaire's captain" and may have suffered from machoism, ie. needing to live up to his image of himself. Consider all the experienced crew walking her decks who must have known that running at speed in the darkness in those waters was folly.
In Captain Smith's day, no subordinates dared question the decisions made by the captain. This was a hold-over custom from the Royal Navy, where the captain was imbued with absolute authority.
That same custom carried over into the beginnings of aviation, right up until a lone KLM Captain caused the deaths of 583 people. That investigation revealed that his co-pilot was worried that something was amiss, but he lacked "assertiveness." And then there were all those dead people. And two 747s destroyed.
We have suffered hundreds of dead people in HEMS as well. As did the airlines, we figured something had to change. Tonight, we expect crew members to voice concerns, using a specific format:
1. You are going to speak up. Use the name of the person you are speaking to.
2. Give voice to your concern. You own it. While we may discuss it later, and it may come to light that your concern was baseless - right now it is valid - and right now we are going to change the way events are unfolding. It's better to be alive and wrong than dead and wrong.
3. State the risks involved. Obviously, a crash and loss of life come to mind. Or perhaps a midnight swim in cold water.
4. Offer a suggested course of action. Is there a way we can still help the patient without putting ourselves at undue risk? Remember, there will be another patient tomorrow, and we need to be here to help them too.
5. You are part of a team, and you have to work together tomorrow. Honestly and calmly ask for affirmation or "buy-in." Try to avoid letting assertion become aggression, but meet aggression calmly and resolutely. No matter whether you are new, inexperienced, or significantly subordinate to the other parties; when that time comes do not hesitate to flip the "can't continue switch." And don't think for one instant that job concerns outweigh safety concerns. You can get another job. Another life? Not so much.
Hopefully, today, a crewmember in a "Titanic" situation would say, "Captain Smith, I am very concerned about our speed and the dark conditions. We can't see an iceberg in front of us until we are on top of it. Hitting an iceberg could seriously damage the ship and perhaps injure our passengers or crew. This could damage your reputation and make you infamous. I recommend we reduce speed to one that will allow us to maneuver clear of an iceberg in our path...
Captain, don't you agree that safety is the best policy; sir?"