Crew resource management
Crew resource management or cockpit resource management (CRM) is a set of training procedures for use in environments where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit.
Crew resource management formally began with a National Transportation Safety Board (NTSB) recommendation made during their investigation of the 1978 United Airlines Flight 173 crash. There a DC-8 crew ran out of fuel over Portland, Oregon while troubleshooting a landing gear problem.
The term "cockpit resource management" (later generalized to "crew resource management") was coined in 1979 by NASA psychologist John Lauber who had studied communication processes in cockpits for several years. While retaining a command hierarchy, the concept was intended to foster a less authoritarian cockpit culture, where co-pilots were encouraged to question captains if they observed them making mistakes.
Crew resource management grew out of the 1977 Tenerife airport disaster where two Boeing 747 aircraft collided on the runway killing 583 people. A few weeks later, NASA held a workshop on the topic, endorsing this innovative training. United Airlines was the first airline to provide CRM training for its cockpit crews in 1981. By the 1990s, it had become a global standard.
United Airlines additionally trained their flight attendants to use CRM in conjunction with the pilots to provide another layer of enhanced communication and teamwork. Studies have shown that by both work groups using CRM together, communication barriers are reduced and problems can be solved more efficiently, leading to increased safety. CRM training concepts have been modified for application to a wide range of activities where people must make dangerous time-critical decisions. These arenas include air traffic control, ship handling, firefighting, and medical operating rooms.
CRM aviation training has gone by several names, including cockpit resource management, flightdeck resource management, and command, leadership, and resource management, but the current generic term, crew resource management, was widely adopted. When CRM techniques are applied to other arenas, they are sometimes given unique labels, such as maintenance resource management or maritime resource management.
CRM training encompasses a wide range of knowledge, skills, and attitudes including communications, situational awareness, problem solving, decision making, and teamwork; together with all the attendant sub-disciplines which each of these areas entails. CRM can be defined as a management system which makes optimum use of all available resources—equipment, procedures and people—to promote safety and enhance the efficiency of operations.
CRM is concerned with the cognitive and interpersonal skills needed to manage resources within an organized system, not so much with the technical knowledge and skills required to operate equipment. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork. In many operational systems as in other walks of life, skill areas often overlap with each other, and they also overlap with the required technical skills. Furthermore, they are not confined to multi-crew craft or equipment, but also relate to single operator equipment or craft as they invariably need to interface with other craft or equipment and various other support agencies in order to complete a mission successfully.
CRM training for crew has been introduced and developed by aviation organizations including major airlines and military aviation worldwide. CRM training is now a mandated requirement for commercial pilots working under most regulatory bodies worldwide, including the FAA (U.S.) and JAA (Europe). Following the lead of the commercial airline industry, the U.S. Department of Defense began formally training its air crews in CRM in the mid 1980s. Presently, the U.S. Air Force and U.S. Navy require all air crew members to receive annual CRM training, in an effort to reduce human-error caused mishaps. The U.S. Army has its own version of CRM called Aircrew Coordination Training Enhanced (ACT-E).
Skills of CRM
The primary goal of CRM is enhanced situational awareness, self awareness, leadership, assertiveness, decision making, flexibility, adaptability, event and mission analysis, and communication. Specifically, CRM aims to foster a climate or culture where authority may be respectfully questioned. It recognizes that a discrepancy between what is happening and what should be happening is often the first indicator that an error is occurring. This is a delicate subject for many organizations, especially ones with traditional hierarchies, so appropriate communication techniques must be taught to supervisors and their subordinates, so that supervisors understand that the questioning of authority need not be threatening, and subordinates understand the correct way to question orders.
Cockpit voice recordings of various air disasters tragically reveal first officers and flight engineers attempting to bring critical information to the captain's attention in an indirect and ineffective way. By the time the captain understood what was being said, it was too late to avert the disaster. A CRM expert named Todd Bishop developed a five-step assertive statement process that encompasses inquiry and advocacy steps:
- Opening or attention getter - Address the individual. "Hey Chief," or "Captain Smith," or "Bob," or however the name or title that will get the person's attention.
- State your concern - Express your analysis of the situation in a direct manner while owning your emotions about it. "I'm concerned that we may not have enough fuel to fly around this storm system," or "I'm worried that the roof might collapse."
- State the problem as you see it - "We're showing only 40 minutes of fuel left," or "This building has a lightweight steel truss roof, and we may have fire extension into the roof structure."
- State a solution - "Let's divert to another airport and refuel," or "I think we should pull some tiles and take a look with the thermal imaging camera before we commit crews inside."
- Obtain agreement (or buy-in) - "Does that sound good to you, Captain?"
These are often difficult skills to master, as they may require significant changes in personal habits, interpersonal dynamics, and organizational culture.
United Airlines Flight 173
United Airlines Flight 173 crew was making an approach to the Portland International Airport on the evening of Dec 28, 1978 when they experienced a landing gear abnormality. The captain decided to enter a holding pattern so they could troubleshoot the problem. The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply. Only when the engines began flaming out did he realize their dire situation. They crash landed in a wooded suburb of Portland, Oregon, over six miles short of the runway. Of the 189 people aboard, two crewmembers and eight passengers died. The NTSB made several recommendations in their report including:
“Issue an operations bulletin to all air carrier operations inspectors directing them to urge their assigned operators to ensure that their flightcrews are indoctrinated in principles of flightdeck resource management, with particular emphasis on the merits of participative management for captains and assertiveness training for other cockpit crewmembers. (Class II, Priority Action) (X-79-17)”
The NTSB Air Safety Investigator who wrote this recommendation was aviation psychologist, Dr. Alan Diehl. He was assigned to investigate this accident and realized it was similar to several other major airline accidents including the Eastern Airlines Lockheed-1011 crash into the Everglades and the runway collision between Pan Am and KLM Boeing-747s at Tenerife. Dr. Diehl was familiar with the innovative research being conducted at NASA’s Ames Research Center and elsewhere and was convinced these embryonic CRM training concepts could reduce the likelihood of human error.
United Airlines Flight 232
Captain Al Haynes, pilot of United Airlines Flight 232, credits Crew Resource Management as being one of the factors that saved his own life, and many others, in the Sioux City, Iowa, crash of July 1989.
...the preparation that paid off for the crew was something ... called Cockpit Resource Management.... Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said, goes. And we lost a few airplanes because of that. Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about. And we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced [under those failure conditions], any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn't used [CRM], if we had not let everybody put their input in, it's a cinch we wouldn't have made it.
Air France Flight 447
One analysis blames failure to follow proper crew resource management procedures as being a contributing factor that led to the 2009 fatal crash into the Atlantic of Air France Flight 447 from Rio de Janeiro to Paris.
Following resolution of an earlier incident with a faulty pitot tube that lasted a few minutes,[not in citation given] the pilot-in-command left to take a rest break, leaving control in the hands of the copilots. When the two copilots were operating the Airbus around 02:11:21, it was not clear which one of the two was in charge of the plane, nor did the copilots communicate with each other about who was in control of the plane.
Following recovery of the black box two years later, various independent analyses were published, both before and after the official report by the BEA, France's air safety board. One was a French report in the book "Erreurs de Pilotage" which leaked the final minutes of recorded cockpit conversation. On December 6, 2011, Popular Mechanics published an analysis of the accident including a translation of the leaked conversation accompanied by a step-by-step commentary.
Speaking about the actions of the two copilots in the cockpit in the minutes before the aircraft crashed into the ocean, the article commentary says,
The men are utterly failing to engage in an important process known as crew resource management, or CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, and who is doing what.
First Air Flight 6560
The Canadian Transportation Safety Board determined that failure of Crew Resource Management was in large part responsible for the crash of First Air Flight 6560, a Boeing 737-200, in Resolute, Nunavut on 20 August 2011. A malfunctioning compass gave the crew an incorrect heading, although the Instrument Landing System and Global Positioning System indicated they were off course. The first officer made several attempts to indicate the problem to the captain, and suggested making a go-around several times during the approach, however failure to follow airline procedures and a lack of a standardized communication protocol to indicate a problem led to the captain dismissing the first officer's warnings. Both pilots were also overburdened with making preparations to land, resulting in neither being able to pay full attention to what was happening.
First Air increased the time dedicated to Crew Resource Management in their training as a result of the accident, and the TSB recommended that regulatory bodies and airlines work to standardize CRM procedures and training in Canada.
The basic concepts and ideology that make CRM successful with aviation air crews have also proven successful with other related career fields. Several commercial aviation firms, as well as international aviation safety agencies, began expanding CRM into air traffic control, aircraft design, and aircraft maintenance in the 1990s. Specifically, the aircraft maintenance section of this training expansion gained traction as Maintenance Resource Management (MRM). In an effort to standardize the industry wide training of this team-based safety approach, the FAA (U.S.) issued Advisory Circular 120-72, Maintenance Resource Management Training in September 2000.
Following a study of aviation mishaps over the 10-year period 1992-2002, the United States Air Force determined that close to 18% of its aircraft mishaps were directly attributable to maintenance human error. Unlike the more immediate impact of air crew error, maintenance human errors often occurred long before the flight where the problems were discovered. These "latent errors" included such mistakes as failure to follow published aircraft manuals, lack of assertive communication among maintenance technicians, poor supervision, and improper assembly practices. In 2005, to specifically address these maintenance human error-induced root causes of aircraft mishaps, Lt Col Doug Slocum, Chief of Safety at the Air National Guard's 162nd Fighter Wing, Tucson, AZ, directed that the base's CRM program be modified into a military version of MRM.
In mid-2005, the Air National Guard Aviation Safety Division converted Slocum's MRM program into a national program available to the Air National Guard's flying wings, spread across 54 U.S. states and territories. In 2006, the Defense Safety Oversight Council (DSOC) of the U.S. Department of Defense recognized the mishap prevention value of this maintenance safety program by partially funding a variant of ANG MRM for training throughout the U.S. Air Force. This ANG initiated, DoD-funded version of MRM became known as Air Force Maintenance Resource Management, AF-MRM, and is now widely used in the U.S. Air Force.
The Rail Safety Regulators Panel of Australia has adapted CRM to rail, Rail Resource Management, and developed a free kit of resources. Operating train crews at the National Railroad Passenger Corporation (Amtrak) in the United States are instructed on CRM principles during yearly training courses.
Following the successes experienced in the aviation community, Crew Resource Management (CRM) was identified as a potential safety improvement program for the fire services. Specifically, Ted Putnam, Ph.D., wrote a paper that applied CRM concepts to the tragic and violent deaths of 14 Wildland firefighters on the South Canyon Fire in Colorado.
From this paper a movement was initiated in the Wildland and Structural Fire Services to apply the Aviation CRM concepts to emergency response situations. Various programs have since been developed to train emergency responders in these concepts and to help track where breakdowns occur in these stressful environments.
Elements of CRM have been applied in U.S. healthcare since the late 1990s, specifically in infection prevention. For example, the so-called "central line bundle" of best practices recommends using a checklist when inserting a central venous catheter. Unlike in the cockpit the observer checking off the checklist is usually lower ranking than the person inserting the catheter (nurse practitioner or MD). The observer is encouraged to communicate when elements of the bundle are not executed for example a breach in sterility has occurred
A division of the United States Department of Health and Human Services, the Agency for Healthcare Quality and Research (AHRQ), also provides training based in CRM principles to healthcare teams at no cost. This training, called TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), and the program is currently being implemented in hospitals, long-term care facilities, and primary care clinics around the world. Specifically TeamSTEPPs was designed to improve patient safety by teaching healthcare providers how better collaborate with each other by using various tools such as huddles, debriefs, handoffs, and check-backs. Although there have been attempts to implement TeamSTEPPS in settings around the world, there is evidence to suggest that TeamSTEPPS interventions are not universally effective.
- Threat and error management
- Single pilot resource management
- Tenerife disaster
- Sterile Cockpit Rule
- Line Oriented Flight Training
- Helmet fire
- Air France Flight 447
- British European Airways Flight 548
- Eastern Air Lines Flight 401
- United Airlines Flight 173
- Saudia Flight 163
- Maintenance Resource Management
- Diehl, Alan (2013) "Air Safety Investigators: Using Science to Save Lives-One Crash at a Time." Xlibris Corporation. ISBN 9781479728930. http://www.prweb.com/releases/DrAlanDiehl/AirSafetyInvestigators/prweb10735591.htm
- Capt. Al Haynes (May 24, 1991). "The Crash of United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff.
- "United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff.
- Langewiesche, William (October 2014). "The Human Factor". Vanity Fair. Retrieved 2014-09-25.
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- Air Force Instruction 11-290: http://www.e-publishing.af.mil/shared/media/epubs/AFI11-290.pdf
- OPNAVINST 1542.7C: https://www.netc.navy.mil/nascweb/crm/1542_7c.pdf
- Brown, Douglas. "ACT-E Update". Knowledge. US Army Safety Center. Retrieved 12 October 2013.
- International Association of Fire Chiefs (2003). "Crew Resource Management: A positive change for the fire service" (PDF). Retrieved 6 September 2010.
- ["Air Crash Investigation: Focused on Failure"] Discover Channel/National Geographic Program "Mayday" S12 E08
- NTSB report: Eastern Airlines, Inc, L-1011, N310EA, Miami, Florida, December 29, 1972, NTSB (report number AAR-73/14), June 14, 1973
- International Civil Aviation Organization,Circular 153-An/56, Mortreal, Canada, 1978)
- Capt. Al Haynes (May 24, 1991). "The Crash of United Flight 232". Archived from the original on October 26, 2013. Retrieved 2013-06-04. Presentation to NASA Dryden Flight Research Facility staff.
- Otelli, Jean-Pierre (October 13, 2011). Erreurs de pilotage Tome 5 [Pilot Error vol. 5] (in French). Altipresse. ISBN 979-1-090465-03-9.
- Wise, Jeff (6 December 2011). "What Really Happened Aboard Air France 447". Popular Mechanics. ISSN 0032-4558. Archived from the original on 4 November 2013. Retrieved 22 June 2013.
- FAA AC 120-72: http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/3e5ec461ecf6f5e886256b4300703ad1/$FILE/AC%20120-72.pdf
- U.S. Air Force Safety Center, 2003: http://web.archive.org/web/20030624092721/http://www.af.mil/factsheets/factsheet.asp?fsID=153
- Air Force MRM: http://www.afmrm.org/
- Institute for Healthcare improvement. Central Line Bundle. available at http://app.ihi.org/imap/tool/#Process=e876565d-fd43-42ce-8340-8643b7e675c7,retrieved 7-18-13 and Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Available at http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf ,retrieved 7-18-13
- U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research; http://teamstepps.ahrq.gov/aboutnationalIP.htm
- Stewart, Greg L.; Manges, Kirstin A.; Ward, Marcia M. "Empowering Sustained Patient Safety". Journal of Nursing Care Quality. 30 (3): 240–246. doi:10.1097/ncq.0000000000000103.