Shifting the Culture: How Crew Resource Management Can Enhance Team Dynamics in Neurosurgery

Introduction

Two fully occupied jumbo jets are on the runway in dense fog—one preparing to taxi to the terminal, the other readying for takeoff. In the cockpit, the first officer echoes the latest radio message, saying, “We are now at takeoff,” although he could have said “We are taking off.” The captain, impatient, interrupts: “We're going,” releases the brakes, and accelerates the plane down the runway. Twenty seconds later, the flight engineer asks, “So, he hasn't left there yet?” The captain replies, “What do you say?” and the engineer repeats, “Hasn't he left there yet, this Pan American?” The captain, brusque, responds, “Of course.” Fourteen seconds later, the cockpit voice recorder captures the devastating sounds of impact. This tragic collision would claim 583 lives in what remains one of the deadliest accidents in civil aviation history—the Tenerife disaster.

The Tenerife tragedy, like many aviation catastrophes, revealed critical issues rooted in strict hierarchies, flawed decision-making, and miscommunication. These so-called “soft skills”—team leadership, decision-making, and situational awareness—were profoundly lacking, leading to misinterpretations and fatal mistakes. Other tragic examples, such as the 1978 crash of United Airlines Flight 173 or the 2009 crash of Air France Flight 447, show similar patterns where the flight crews were unaware of urgent problems, with fatal consequences. In each of these cases, communication breakdowns, misjudgments, and a failure to heed warning signs were underlying causes. Such failures extend beyond aviation to space exploration. While the 1986 U.S. space shuttle Challenger disaster ostensibly resulted from defective O-rings, a deeper investigation revealed critical issues in organizational communication, safety standard deviations, and a failure to escalate engineering concerns.[1] National Aeronautics and Space Administration (NASA) managers dismissed engineers' repeated warnings, with one senior engineer predicting the previous year that “total element failure…could cause loss of life or vehicle.”[2] During discussions the night before the final launch, engineers were unable to clearly convey their concerns and were ultimately disregarded by NASA leadership.[1]

Human error and in-flight loss of control (LOC) have historically been leading causes of fatal accidents, according to various commercial aircraft accident statistics.[3] [4] [5] In response to a series of catastrophic accidents attributed to human error, NASA held its first workshop in 1979, titled “Resource Management on the Flight Deck,” which underscored the critical connection between aviation accidents and failures in interpersonal communication, decision-making, and leadership within flight crews.[6] This workshop laid the foundation for modern Crew Resource Management (CRM), a strategy designed to minimize human error and enhance teamwork and communication in complex, high-risk environments. Since then, CRM has become a standard in both civil and military aviation, though its development and implementation have varied by country and regulatory authority. In the United States, CRM is regulated by the Federal Aviation Administration (FAA), while global standards are set by international organizations such as the International Civil Aviation Organization (ICAO).[7] [8] Today, CRM training is an integral part of preparation for flight crew members and other safety-critical personnel, with guidelines such as FAA Advisory Circulars prescribing its implementation. The adoption of CRM has contributed significantly to reducing accidents rooted in human error, though its precise impact on lives saved or aircraft preserved may never be fully quantified.[4] [8] [9] [10]

Authors' Contributions

M.A.K. and N.D. had the research idea. M.A.K., C.v.S., and N.D. contributed to study conception and design. Data collection and literature review were performed by M.A.K., N.D., C.v.S., F.M., and C.S. M.A.K. wrote the first draft. M.A.K. and N.D. reviewed and edited the draft to the final manuscript. N.D. supervised the work. All authors read and approved the final manuscript.

Declaration of Generative AI and AI-Assisted Technologies in the Writing Process

AI-assisted technology was neither used for the generation, evaluation, or interpretation of the data presented in the manuscript, nor for the creation of text, figures, or tables. AI-based tools (ChatGPT) may have been used to improve language and text readability.

Clinical Trial Number

Not applicable.

Ethical Approval

Not applicable.

Publication History

Received: 22 March 2025

Accepted: 16 April 2025

Article published online:
26 June 2025

• References

• 1 Committee on Science and Technology - House of Representatives. Investigation of the Challenger Accident: Ninety-Ninth Congress; Second Session. U.S. Government; 1986
• 2 Boisjoly RM, Kapp JR. SRM O-Ring Erosion/Potential Failure Criticality. In: Letters of Note; 1985;2870:FY86:073
• 3 Ancel E, Shih A. The Analysis of the Contribution of Human Factors to the In-flight Loss of Control Accidents. Paper presented at: 12th AIAA Aviation Technology, Integration, and Operations (ATIO) Conference and 14th AIAA/ISSMO Multidisciplinary Analysis and Optimization Conference. IN: Indianapolis. September 17–19, 2012. National Aeronautics and Space Administration, American Institute of Aeronautics and Astronautics.
• 4 Broome DP. Accident reduction through crew resource management. J Aviat Aerosp Educ Res 2011; 20: 13-21
• 5 Lyssakov N, Lyssakova E. Human Factor as a Cause of Aircraft Accidents. Atlantis Press; 2019: 130-132
• 6 Cooper G, White M, Lauber J. et al. Resource Management on the Flight Deck. Paper presented at: Proceedings of a NASA/Industry Workshop (NASA Conference Proceedings-2120); 1979.
• 7 Driskell JE, Adams RJ. Crew Resource Management: An Introductory Handbook. U.S. Department of Transportation, Federal Aviation Administration, Research and Development Service; Washington, DC: 1992
• 8 Federal Aviation Administration. Advisory Circular AC No: 120–51E CREW RESOURCE MANAGEMENT TRAINING. Washington, DC: Federal Aviation Administration; 2004
• 9 Diehl A. Does cockpit management training reduce aircrew error? Paper presented at: 22nd International Seminar, International Society of Air Safety Investigators. Canberra, Australia; 1991.
• 10 Flin R, O'Connor P, Mearns K. Crew resource management: improving team work in high reliability industries. Team Perform Manag 2002; 8: 68-78
• 11 Haerkens MH, Jenkins DH, van der Hoeven JG. Crew resource management in the ICU: the need for culture change. Ann Intensive Care 2012; 2 (01) 39
• 12 Clancy CM. TeamSTEPPS: optimizing teamwork in the perioperative setting. AORN J 2007; 86 (01) 18-22
• 13 Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual 2007; 22 (03) 214-217
• 14 King HB, Battles J, Baker DP. et al. Advances in Patient Safety TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. In: Henriksen K, Battles JB, Keyes MA. et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008
• 15 Mitchell P, Dale T. Side errors in neurosurgery and human factors training. Acta Neurochir (Wien) 2015; 157 (03) 487-491
• 16 McCulloch P, Kaul A, Wagstaff GF, Wheatcroft J. Tolerance of uncertainty, extroversion, neuroticism and attitudes to randomized controlled trials among surgeons and physicians. Br J Surg 2005; 92 (10) 1293-1297
• 17 McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009; 18 (02) 109-115
• 18 Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA. A multicenter trial of aviation-style training for surgical teams. J Patient Saf 2010; 6 (03) 180-186
• 19 Duclos A, Peix JL, Piriou V. et al.; IDILIC Study Group. Cluster randomized trial to evaluate the impact of team training on surgical outcomes. Br J Surg 2016; 103 (13) 1804-1814
• 20 Weld LR, Stringer MT, Ebertowski JS. et al. TeamSTEPPS improves operating room efficiency and patient safety. Am J Med Qual 2016; 31 (05) 408-414
• 21 Gross B, Rusin L, Kiesewetter J. et al. Crew resource management training in healthcare: a systematic review of intervention design, training conditions and evaluation. BMJ Open 2019; 9 (02) e025247
• 22 Michalak SM, Rolston JD, Lawton MT. Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder?. J Neurosurg 2016; 124 (06) 1794-1804
• 23 Rocque BG. Letter to the Editor: Error in the eye of the beholder: crew resource management in neurosurgery. J Neurosurg 2016; 125 (06) 1616-1617