Learning from Aviation Project Resource Management to avoid Project Failure

Abstract

In aviation it has long been established that based on technical advances alone airlines would not achieve acceptable flight safety standards. As a consequence, the industry invested heavily in understanding and coping with so called human factors. An integrated and comprehensive approach to training called Crew Resource Management was developed. This was initiated after the Tenerife Airport disaster in 1977, the, until today, deadliest accident in aviation history. This article reviews the case of Tenerife and compares it with the case of the construction project of Berlin Brandenburg airport, one of the most prominent contemporary failures in the project management arena. The analysis shows that in Berlin and in Tenerife similar patterns of behavior significantly contributed to undesirable outcomes. It is suggested for project organizations to consider learning from aviation and to derive an approach for Project Resource Management from the established Crew Resource Management methodology.

Full text

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 1 of 11
Learning from Aviation Project Resource Management to avoid
Project Failure
Dirk Nicolas Wagner
Karlshochschule International University
Abstract
In aviation it has long been established that based on technical advances alone
airlines would not achieve acceptable flight safety standards. As a consequence, the
industry invested heavily in understanding and coping with so called human factors.
An integrated and comprehensive approach to training called Crew Resource
Management was developed. This was initiated after the Tenerife Airport disaster in
1977, the, until today, deadliest accident in aviation history. This article reviews the
case of Tenerife and compares it with the case of the construction project of Berlin
Brandenburg airport, one of the most prominent contemporary failures in the project
management arena. The analysis shows that in Berlin and in Tenerife similar
patterns of behavior significantly contributed to undesirable outcomes. It is
suggested for project organizations to consider learning from aviation and to derive
an approach for Project Resource Management from the established Crew Resource
Management methodology.
Key words: project management, project failure, human factors, Crew Resource
Management (CRM), risk management
Introduction
Projects often do not reach their objectives. Irrespective of the industry or even the
sector concerned, they fail in the sense that they do not meet their schedule, cost
and scope respectively quality objectives (Flyvbjerg et al., 2002; Altshuler/ Luberoff,
2003; Priemus et al., 2008). It is widely accepted that project failure can be traced
back to technical, psychological and political-economic reasons (Flyvbjerg, 2009).
Empirical evidence suggests that technical causes are less relevant than causes that
are rooted in behaviors and interactions of humans involved in the management of
projects (PMI, 2016). In such a context, it is not surprising that project management
emerged as a dedicated discipline. Yet, limited project success rates in times of
accelerated projectification of business and social life call for an ongoing search of
improved and better practices, also outside the own profession.
Below, the case is made for learning from aviation. In aviation it has long been
established that based on technical advances alone airlines would not achieve
acceptable flight safety standards. As a consequence, the industry invested heavily
in understanding and coping with so called human factors. It all started in 1977 with
the, until today, deadliest accident in aviation history, the Tenerife Airport disaster.
Following the Tenerife accident, the aviation industry identified a need for the
development of skills and managerial techniques. An approach today known as
Crew Resource Management (Kanki et al., 2010) was developed. The case analysis

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 2 of 11
is used to reflect how the discipline of project management can learn from the
aviation industries Crew Resource Management (CRM) methodology.
For the purpose of this case study, the causes of the well documented and
researched Tenerife accident are compared with one of the most significant
contemporary and thus also well documented disasters in project management, the
endeavor to build a new airport for Germany’s capital Berlin, Flughafen Berlin
Brandenburg “Willy Brandt” (BER).
The Tenerife airport disaster
1
On 27 March 1977 two Boeing 747 jumbo jets collided on the runway of Tenerife
airport, killing 583 people. At the time of the accident, Los Rodeos airport is
surrounded by fog. But this turns out to be only one of many contributing factors to a
catastrophic outcome. The two planes involved are on an unplanned stopover at
Tenerife as a bomb alarm at their original destination, Gran Canaria airport,
prevented them from landing there. Due to the situation at Gran Canaria, Los
Rodeos airport is extremely busy with grounded airliners. Even the taxiways to the
runways are used to park airplanes. Only two air traffic controllers are on duty to
handle the crowded situation. KLM flight 4805 and Pan Am flight 1736 have been
waiting at Tenerife for more than three hours. They are under time pressure to leave
as the crews approach the regulatory cap for maximum flight and duty time.
When Gran Canaria reopens, both, the KLM and the Pan Am 747 jumbo jets have to
taxi on the runway to get into position for takeoff. Visibility on the runway is very bad
due to layers of low laying clouds. The airplanes’ crews cannot see each other. KLM
4805 is the first to be ready for takeoff, whilst in the fog Pan Am 1736 misses an exit
to clear the runway.
The pilot aboard the KLM 747, captain Jacob Veldhuyzen van Zanten (50) is very
experienced and a senior member of staff at the airline. In addition to his duties as
pilot he is head of the airline’s flight training department. On the runway he opens the
throttles and the jumbo jet slightly moves forward when his co-pilot, Klaas Meurs
(32), says “Wait a minute, we don’t have an ATC clearance” to which the captain
replies “No, I know that, go ahead, ask.”
Subsequently, KLM 4805 receives air traffic control (ATC) clearance for the route to
take but not yet a clearance for take-off. The co-pilot reads back the instructions
received and adds “We are now at takeoff”. The captain immediately says “Let’s
go….check thrust” even before air traffic control replies to the co-pilot “O.K….stand
by for takeoff….I will call you.” Obviously, the tower interprets the co-pilot’s sentence
to be “We are now at takeoff [position]” but not as “We are now taking-off”.
At the same time inside the other Boeing 747, the Pan Am crew listens to the
beginning of the radio conversation between the KLM and the tower and as a
1
The summary provided is based on the official reports by the Netherlands Aviation Safety Board (1977), the
Spanish government (Ministerio de Transportes y Comuniciacones, 1978) and by Roitsch et al. (1979) on behalf
of the Airline Pilots Association (ALPA).

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reaction reports to the controller “We are still taxiing down the runway”. This radio
message overlaps with the radio message from the tower to the KLM and causes a
shrill noise in the KLM cockpit right after the “O.K….” they hear from the controller.
Interpreting the “O.K” as clearance for takeoff, captain van Zanten accelerates with
no further intervention from his co-pilot.
After the incident, the voice recorder unveils a last conversation from the cockpit
where the third crew member, flight engineer Willem Schreuder (48), reluctantly
questions about the Pan Am jumbo on the runway: “Is he not clear that Pan
American?” and van Zanten empathically replied “Oh, yes”.
A few seconds later and with increasing speed, the nose of the KLM points up when
the crew recognizes the Pan Am 747 as an obstacle on the runway. Less than ten
seconds after Willem Schreuder’s question, the impact takes place, the planes
collide and burst into flames. 583 people die. Only 63 people situated in the front of
the Pan Am jumbo jet survive the accident.
The opportunity to learn from aviation
As the Tenerife case illustrates, aviation incidents may arise out of complex settings.
Yet, in retrospective it is regularly possible to gain an almost full understanding of the
causes and effects of an incident. Several factors facilitate such a comprehensive
understanding: The number of relevant actors involved is small. The technology in
use is highly specified and well known. Processes are highly standardized and tightly
regulated. Relevant events take place in a relatively short time-frame. Human actors,
technology as well as many environmental factors are monitored and recorded.
In comparison, project management settings are, even in retrospective, by far less
specifiable. Compared to cockpit situations, already small projects appear to be
extremely vague and diverse with many more or less involved actors as well as other
influences which are difficult to oversee. Events which contribute to project success
or failure may take place in close geographical proximity or at long distance. They
may occur as a tight sequence of events or in disjoint time intervals.
The investigations into the Tenerife airport disaster came to the conclusion that
“significant human aspects and system aspects, led, step by step, toward tragic
human error, and then neutralized the opportunities for reversal of the final outcome”
(Roitsch et al., 1979). Exactly such meanwhile scientifically so called “human factors”
(Badke-Schaub et al., 2012) turn comprehensively investigated and documented
aviation incidents into a source of learning for other contexts where human decision
makers act for the better or the worse. Hagen (2013) proposes that all kind of
organizations can avoid error and failure by learning from experience made in
aviation. Put more concretely, what took place at Tenerife airport appears to show
patterns of human behavior and interaction that are familiar also in other contexts
like for example industrial, construction or software projects. The research
proposition of this case study is that the detailed insights from the incident in
Tenerife can be matched with observations made in project management
environments. To review this proposition, the causes and contributing factors of the
Tenerife accident are outlined below and related to factors that have been found to

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 4 of 11
contribute to the failure of building the airport Berlin-Brandenburg (BER) on time, on
budget and on scope.
BER can be classified as the most significant failed public construction project in
Germany in the last decade. At the current stage the new airport exceeds the budget
communicated at the beginning of the construction works in 2007 of € 2 billion by € 4
billion and will thus incur total costs of circa € 6 billion. The airport was scheduled to
be completed in 2012 but it will not be operational before autumn 2017 which means
that it is half a decade late. In total, more than 125.000 relevant construction defects
have been counted, a range of fraudulent activities have been unveiled and at least
four fatal accidents occurred (Fuchs et al., 2015; Deutscher Bundestag, 2014;
Abgeordnetenhaus Berlin, 2012). The following analysis draws on a preceding
review undertaken by Wagner (2016).
Causes for the Tenerife accident and comparable patterns in Berlin
The investigations into the Tenerife accident came to the straightforward conclusion
that the fundamental cause of the accident was the fact that the KLM captain took off
without clearance. Neither did he obey the “stand by for takeoff” by the tower, nor did
he interrupt the takeoff when Pan Am reported they were still on the runway.
With the aim to explain why an experienced pilot supported by a qualified crew
committed such a basic error, the authorities identified a number of contributing
behavioral factors:
1. Time-pressure: The limitations of duty time put the crew under time pressure
to either take off soon or to interrupt the flight. An interruption of the flight
would have meant additional costs and organizational complications for the
airline as well as further inconvenience for the passengers.
Real or created time-pressure is a regular phenomenon on projects of all
kinds. Berlin airport is a particularly extreme example. Early plans targeted for
the airport to be put into operation as early as 2007. As the construction works
began only in 2008, time-pressure existed from the very beginning on.
Subsequently, repeatedly revised opening dates were put forward, debated,
cancelled and rescheduled. The management team, main contractors and
subcontractors were put under pressure to meet the schedule prescribed at a
given time. Costly trade-offs with respect to acceleration costs, non-
compliance with regulations or quality standards were made to meet
unrealistic schedules which later had to be dropped. According to the
investigations by different commissions of inquiry, assurance of schedules
had absolute priority which led to dubious claim management processes
(Abgeordnetenhaus Berlin, 2016; Deutscher Bundestag, 2014;
Amann/Scherff, 2013).
2. Emotions and post-factual behavior: Potentially caused by the felt time-
pressure, the impatient mood of the KLM captain and a “desire to be airborne”
(Ministerio de Transportes y Comuniciacones, 1978) influenced how facts
were dealt with and how decision making in the cockpit proceeded.

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 5 of 11
A “desire to be airborne” can also be detected at Berlin airport. It is common
knowledge in the construction industry that incomplete planning, especially of
technical building infrastructure, is a notorious weak spot of new-build
projects. Nevertheless, management decided to move into implementation
phase based on insufficient and deficient initial planning (Siegle, 2014).
Despite obvious awareness of considerable risks and in ignorance of relevant
facts, management did not give up the opening date targeted for autumn 2012
until only three weeks before the planned ceremony. The investigation report
presented to Berlin parliament concluded that “a collective loss of reality”
descended on the involved actors (Abgeordnetenhaus Berlin, 2016).
3. Imprecise communication and confirmation bias: At Los Rodeos various
factors resulted in imprecise communication. The air traffic controller spoke
with a heavy Spanish accent and was difficult to understand for the crew
members. Then, technically, the two overlapping radio transmissions resulted
in a disturbing whistling sound and loss of clarity. Even more importantly,
inadequate language was used, especially when the KLM’s co-pilot read back
the ATC clearance and added “we are now at takeoff” and the tower replied
commencing with “OK…” At this stage, the KLM crew was already in a
confirmation bias mode where they only heard what they wanted to hear.
On large projects like BER the potential for imprecise communication is
disproportionately greater than on the runway. With numerous companies
meeting at the workface it is difficult to establish one corporate language with
one standard terminology. Communication at the interface between the
business and the supervising political sphere also turns out to be a challenge.
The government inquiry into the sudden cancellation of the planned opening
in 2012 identified problematic communication behavior by various parties. The
managing director for example requested for minutes of meeting to be
disarmed by taking out the word “extremely” when referring to the critical
paths of the project. Another example is provided by the controlling reports
which used a traffic light system to highlight problems. Already half a year
before the unexpected cancellation, critical actions showed red evaluations
but the overall evaluation remained yellow. Asked for explanation in a
supervisory board meeting, project management commented that the
intention was not to undermine the pressure to complete the works by sending
negative (red) signals. The report concluded that there was a lack of adequate
communication and a lack of realistic assessment of risks (Abgeordnetenhaus
Berlin, 2016).
4. Steep authority gradient: In the 1970s the flight captain on board of an
airliner was regularly perceived as a ‘Master of the Skies’ whose decisions
were not to be questioned. On KLM flight 4805 co-pilot Klaas Meurs dared to
intervene once when there was no ATC clearance but kept quiet afterwards.
Flight engineer Schreuder’s shy question about the Pan Am on the runway
was empathically pushed aside by the captain.

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 6 of 11
On the Berlin airport project many indicators point towards steep authority
gradients. Repeatedly, unrealistic project plans and budgets were followed.
Problems were not reported or not escalated, or both. The airport’s failure to
identify and mitigate problems with the preventive fire protection system
became a symbol for dysfunctional management structures on the project
(Amann/Scherff, 2013). When the numerous problems at BER escalated a
decision was made to get more of the same: Hartmut Mehdorn, a top-
manager known for his direct and authoritarian leadership-style, was
appointed as a new CEO in 2013 and later criticized by the supervisory board
for nurturing a climate of fear (Beikler, 2014). In 2014 a government enquiry
brought to light that the volume of change orders had reached a value of € 1.4
billion. By the airport’s management this was framed as “normal project
business” (Deutscher Bundestag, 2014; F.A.Z, 2014). In fact, the sum
equaled a remarkable 70% of the original budget. This reminds of captain van
Zanten’s “Oh yes” and shows that even when it is already too late, authority
may still be used to ignore or mask facts.
Very different from Tenerife, in the government inquiry in Berlin concludes that there
does not exist one fundamental cause for the disaster (Abgeordnetenhaus Berlin,
2016). But although the challenges of safely conducting civil aviation and completing
a major new-build project are very different from each other, comparable patterns of
underlying human factors seem to have undesirable impact.
Crew Resource Management as an answer
The investigations into the Tenerife accident and into a United Airlines crash a few
months later in 1978 led to recommendations for new, innovative forms of training to
cope with human error. What started out as Cockpit Resource Management training
was soon expanded to all crew members of an aircraft and thus became Crew
Resource Management (Kanki et al., 2010; Hagen, 2013).
CRM training is designed to avoid crisis situations and to improve the competencies
of whole teams to cope with a crisis (Badke-Schaub et al., 2010). As such, it is
supposed to help avoiding, identifying and addressing human errors. In its
standardized form, the training goes through three phases: 1. Initial awareness
training to convey the essentials of human factors concepts and know-how. 2.
Exercises and feedback in realistic settings for complete crews. 3. Refresher
trainings in regular intervals based on various methods (Federal Aviation
Administration, 2004; Kanki et al., 2010). CRM training is regularly composed of but
not limited to the following building blocks:
2
Situational Awareness: To comprehend current system and environmental
conditions, anticipate future changes. To consciously avoid complacency and to
2
Worldwide, a variety of different approaches and CRM trainings designed to meet the needs of the individual
organization concerned exist. The following summary is intended to be illustrative rather than comprehensive
with the intention to be insightful from a project management perspective. It is based on ICAO (1998), Federal
Aviation Administration (2004), Kanki et al. (2010) and Scheiderer/Ebermann (2010).

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 7 of 11
watch over system and environment changes, informing other team members of
potential threats and errors.
Workload Management: To ensure good preparation and sufficient planning
including relevant communication. To prioritize and delegate effectively to maintain
focus on primary tasks. To continuously monitor progress, avoid distraction, remain
vigilant and, if necessary, respond without undue delay.
Human Error: To know about the origins of error and to differentiate types of error.
To understand concurrent failures and chains of errors as well as available
resources and redundancies when dealing with threats and errors in order to
enhance the competency to manage errors (error prevention, resistance, detection
and recovery).
Communication: To enable free and open communication with active participation
of all team members at the appropriate time. To use clear and effective language
and to become responsive to feedback. To ensure interactive exchange of
information and an environment where plans are stated and ambiguities resolved.
Decision Making: To detect deviations from desired states, assess problems,
generate alternative actions, identify risks and select the best course of action, which
is subsequently reviewed for the purpose of learning and necessary adaptation.
Leadership & Teamwork: To use appropriate authority in order to ensure a focus
on task and crew member concerns and to support others in completing tasks. To
establish task priorities and to utilize team resources to achieve objectives whilst
contributing to the improvement of team interpersonal relations.
Stress & Fatigue: To know about the origins and the effects of stress and fatigue
which enables team members to recognize and to manage stress and fatigue. To
exercise personal responsibility with regard to factors of stress and fatigue.
In aviation, continued and ongoing training of all crew members is geared to create a
system that makes best possible use of the resources available on board of an
aircraft to promote safety and enhance efficiency. Despite all efforts, for many years
crews and pilots in particular had been reluctant to accept the new approach (Hagen,
2013). It took a decade until another flight incident turned out to be a breakthrough
event for CRM: In 1989 the crew of United Airlines (UAL) flight 811 from Honolulu to
Sidney managed to safely land a fully loaded Boeing 747 after a cargo door failed
and an explosive decompression blew out several rows of seats through a massive
hole in the body of the aircraft. Almost as remarkable as the safe landing was that
the crew publicly emphasized that their CRM training was an important enabler to
rescue the plane, its passengers and the crew (National Transportation Safety
Board, 1992). In his review of the incident, Hagen (2013) shows how the men in the
UAL cockpit interact much more constructively than the KLM crew in Tenerife where
van Zanten, Meurs and Schreuder remained in tragic inner isolation.

PM World Journal Learning from Aviation Project Resource Management
Vol. VI, Issue II – February 2017 to avoid Project Failure
www.pmworldjournal.net Featured Paper Dirk Nicolas Wagner
© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 8 of 11
In the 1990’s, CRM became a mandatory training requirement under most regulatory
bodies for aviation worldwide and the idea spread into many other high risk
industries like health care, fire-fighting or oil & gas.
Project Resource Management as a perspective
Behind the mostly glamorous and rarely catastrophic façade of a high tech driven
aviation industry, Crew Resources Management training has made a quiet but
extremely effective career. Its origins benefited from forensic root cause analyses of
flight incidents. The training modules tackle individual sources of human error and
systematically integrate to deliver synergies not only for the trained individual but
also between the participants as every crew member knows what his or her
colleagues know and how they are trained and requested to act. Therefore, CRM
over the years has had a significant influence on the professional culture on board of
aircrafts. Today, many of the contents of CRM-training can also be found to be part
of the curriculum of more general leadership programs or project-management
trainings. However, it is the focus on human error combined with the systematic roll-
out of the training to all relevant actors which make the approach unique (figure 1.).
Figure 1. The logic of Crew Resource Management
The reasons why projects fail often remain manifold and ambiguous. However, the
combination of the cases of Tenerife and the Berlin presented above, suggests that
typically human but avoidable behaviors contribute errors and unfold dynamics (see
also Wagner, 2016) which lead to error chains that play a significant role for
undesired outcomes. It is a long way to go from such an insight to the
implementation of what may be called Project Resource Management or Company
Resource Management. But for organizations involved in project business it can be
worthwhile asking how valuable it can turn out to be if
 all involved in a project would be able to better recognize errors
 all involved in a project would know about the logic of error chains
 precise and courageous communication would be requested from all
hierarchy levels on a project

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 universal decision making models would be commonly known and could be
requested to be put to use by anyone on a project
 problems could be openly addressed, irrespective of a person’s formal role or
position
 physical and psychological personal limitations would be actively considered
on an individual basis
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© 2017 Dirk Nicolas Wagner www.pmworldlibrary.net Page 11 of 11
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About the Author
Dirk Wagner
Karlshochschule International University
Karlshochschule, Germany
Dirk Nicolas Wagner is Dean of the Faculty for Business Economics &
Management and Professor of Strategic Management at Karlshochschule
International University. Prior to joining Karlshochschule in 2013, he served in
various management positions in the Technical Services Industry in Europe, most
recently as Executive Chairman of the Board of ThyssenKrupp Palmers Ltd. and as
a Director for WWV Wärmeverwertung GmbH & Co KG. His professional
background includes major projects in oil & gas, power and rail infrastructure.
Professor Wagner can be contacted at dwagner@karlshochschule.de