the hint that was not enough: what cockpits learned about speaking up to a senior
Two air crashes, nineteen years apart, have something painful in common. In both, someone junior in the cockpit saw part of the danger and spoke, but softly. Aviation spent decades learning to fix that. What it learned is useful to anyone who has ever had to tell a boss something unwelcome.
By Brightside English editorial team
Reviewed by a Brightside senior coach · · 6 min read
In 1978, a United Airlines jet ran out of fuel near Portland while the crew worked on a landing gear problem. Investigators found the junior crew had raised the fuel, but not forcefully enough. That finding helped shape Crew Resource Management, now standard training. Researchers later showed that juniors tend to hint while seniors command. The lesson: name the problem, name the action, and speak early.
An evening over Portland
On the evening of 28 December 1978, United Airlines Flight 173, a DC-8 from Denver, was approaching Portland, Oregon, with 189 people on board. When the crew lowered the landing gear, something felt and sounded wrong, and a gear indicator did not show what it should. The captain decided to hold near the airport while the crew worked through the problem and prepared the cabin for a possible emergency landing.
According to the National Transportation Safety Board, the aircraft circled south of the airport for about an hour. During that time the fuel kept burning. The first officer asked about the fuel more than once. When the captain spoke of holding for roughly another fifteen minutes, the flight engineer pushed back, as the cockpit voice recorder shows: "Fifteen minutes is gonna really run us low on fuel here."
It was a warning. It was also, in the Board's later judgement, not quite enough. The engines began to stop from fuel exhaustion, and the aircraft came down in a wooded suburban area about six nautical miles southeast of the airport. Ten people died, eight passengers, the flight engineer and a flight attendant, and 23 more were seriously injured. There was no fire.
What the investigators wrote
The NTSB's report, published in June 1979, placed the probable cause on the captain's failure to monitor the fuel state and to respond to it and to his crewmembers' advisories. It then added a contributing factor that would echo for decades: the other two flight crewmembers had either not fully grasped how critical the fuel was, or had not managed to get their concern across to the captain.
The report is careful and humane on this point. It notes that a captain's stature and style can quietly pressure a crew to go along with his thinking. It observes that the first officer made several subtle comments about fuel, but did not state a direct view until an engine had already failed. It recommended that airlines teach flight deck resource management, with participative management for captains and assertiveness training for the rest of the crew.
A workshop gives the idea a name
The timing mattered. In June 1979, NASA hosted an industry workshop in San Francisco called Resource Management on the Flightdeck. In their history of the field, the psychologists Robert Helmreich, Ashleigh Merritt and John Wilhelm describe how research presented there linked most air crashes to human failures in communication, decision making and leadership. At that workshop, they write, the label Cockpit Resource Management, CRM, was applied to training crews to make better use of everyone on the flight deck.
United Airlines started the first comprehensive American CRM programme in 1981. Early courses borrowed heavily from corporate management training, and some pilots dismissed them as charm school. Over the years the training became more practical and more specific to flying, and "cockpit" became "crew" as cabin staff and others were included.
How juniors actually ask
Training people to speak up raised a sharper question: what does speaking up sound like? In the 1990s, Ute Fischer of Georgia Tech and Judith Orasanu of NASA Ames asked pilots to write out, word for word, what they would say to correct a colleague's error in scenarios such as flying toward a storm.
The pattern was striking. Captains mostly gave commands. First officers mostly gave hints: a remark about how bad the weather looked, or a reminder of a target, without naming what should be done. This held, the authors report, across nationalities and genders in their samples. The hint protects the senior person's face. It also leaves them to work out the danger alone.
Then the researchers asked pilots to rate which ways of speaking were most effective. Both captains and first officers favoured what the authors called crew obligation statements, which put the need on the whole crew, something like saying we ought to turn away from the weather now, and preference statements. These sit in the middle: clearer than a hint, less abrupt than an order. Requests that came with a short reason, a problem or goal, were rated more effective than bare requests. Even in high risk situations, crew obligation statements were rated above commands.
Guam, 1997
On 6 August 1997, Korean Air Flight 801, a Boeing 747 from Seoul, crashed into high terrain at Nimitz Hill, Guam, about three miles from the airport, at night and in poor weather. Of the 254 people on board, 228 died.
The NTSB found the probable cause to be the captain's failure to brief and fly the approach properly, and the first officer's and flight engineer's failure to monitor and cross-check him effectively. Captain fatigue and Korean Air's inadequate crew training contributed, and so did the Federal Aviation Administration's inhibition of a ground warning system at Guam. The first officer did call for a missed approach, seconds before impact, but did not challenge the captain's earlier descents, when there would have been time to act.
Korean Air already had a CRM course at the time, adapted from United's. Its training director told investigators that the airline had found it difficult to teach some first officers and flight engineers to challenge the captain. In 1999 the airline announced a reform programme reported by FlightGlobal at around 200 million dollars, including English training for pilots, double the simulator training, more than 100 extra expatriate training captains and a new CRM course built with Delta Air Lines and the University of Texas.
What is disputed
The most famous telling of this story is Malcolm Gladwell's chapter on plane crashes in Outliers (2008). He argued that Korean Air's problems in that era came largely from a hierarchical cultural legacy, and that the airline improved by confronting it.
That explanation is contested. The NTSB itself said it could not determine why the Guam crew did not challenge earlier: poor preparation for the approach, sharing the captain's mistaken picture of where they were, or reluctance to confront him. After the Asiana crash in San Francisco in 2013, the airline pilot and writer Patrick Smith told National Geographic he doubted Korean safety culture of that time was a factor, pointing to the country's expensive aviation overhaul. In The Korea Times, the University of Oslo scholar Vladimir Tikhonov called such cultural theories Orientalist, noting that strict cockpit hierarchies exist elsewhere without higher accident rates. Note too that Fischer and Orasanu found hinting by juniors in every group they studied, including American pilots, and that United 173 was an American crew. The pull toward softening words for a senior is human, not national.
The lesson for the rest of us
Few of us fly aircraft. Many of us sit beside someone senior while something quietly goes wrong: a project lead reading the wrong numbers to a client, a consultant on a ward round about to miss an allergy, a father about to sign a loan the family cannot carry.
The cockpit research suggests three habits.
Name the problem, then the action. A hint ("The deadline looks tight") leaves the other person to finish your thought. Add what you think should happen.
Give one reason. Pilots rated requests with a short problem or goal statement as more effective, and as no less direct.
Speak early, and say it twice if needed. Both NTSB reports dwell on timing. Health care, which took crew resource management ideas from aviation, has turned this into tools: AHRQ's patient safety network describes the TeamSTEPPS CUS tool, where a team member says they are concerned, then uncomfortable, then that this is a safety issue, as a signal to stop and look, alongside a tool it calls the Two-Challenge Rule.
"I think we need to recheck the figures before we send this to the client, because the totals do not match last quarter."
"I am concerned about the timeline. If we commit to Friday, we will miss the testing step. Can we agree Tuesday?"
"I am uncomfortable going ahead. I think this is a safety issue, and I would like us to stop and check."
Sources
- National Transportation Safety Board, Aircraft Accident Report: United Airlines, Inc., McDonnell Douglas DC-8-61, N8082U, Portland, Oregon, December 28, 1978 (NTSB-AAR-79-7), 1979. www.ntsb.gov/investigations/AccidentReports/Reports/AAR7907.pdf
- G. E. Cooper, M. D. White and J. K. Lauber (eds), Resource Management on the Flightdeck, NASA CP-2120, NASA/Industry workshop, San Francisco, 26 to 28 June 1979, published 1980. ntrs.nasa.gov/citations/19800013796
- Robert L. Helmreich, Ashleigh C. Merritt and John A. Wilhelm, The Evolution of Crew Resource Management Training in Commercial Aviation, International Journal of Aviation Psychology 9(1), 1999 (FAA copy). www.faa.gov/sites/faa.gov/files/crmhistory.pdf
- Ute Fischer and Judith Orasanu, Cultural Diversity and Crew Communication, paper at the 50th Astronautical Congress, Amsterdam, 1999. bpb-us-e1.wpmucdn.com/sites.gatech.edu/dist/d/917/files/2018/10/Fischer_Orasanu-AIAA99.pdf
- National Transportation Safety Board, Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997 (NTSB/AAR-00/01), 2000. www.ntsb.gov/investigations/AccidentReports/Reports/AAR0001.pdf
- Andrzej Jeziorski, KAL launches $200 million safety reforms, FlightGlobal, 21 July 1999. www.flightglobal.com/kal-launches-200-million-safety-reforms/27649.article
- Brian Clark Howard, report on Gladwell's Outliers argument and its critics after the Asiana Flight 214 crash, National Geographic, 11 July 2013. www.nationalgeographic.com/adventure/article/130709-asiana-flight-214-crash-korean-airlines-culture-outliers
- Kim Young-jin, Is culture to blame for Asiana crash?, The Korea Times, July 2013. www.koreatimes.co.kr/amp/southkorea/20130711/is-culture-to-blame-for-asiana-crash
- John Day and John T. Paige, Good Catch in the Operating Room (on the TeamSTEPPS CUS tool), AHRQ Patient Safety Network, 2019. psnet.ahrq.gov/web-mm/good-catch-operating-room
Published by The Full Stop, the journal of Brightside English, in the Landmark Moments series. Every factual claim links to a source below; where accounts or findings are disputed, we say so. Sources checked on 26 Oct 2026. Reviewed by a Brightside senior coach. Corrections: see our editorial standard.