Crew resource management or cockpit resource management (CRM)Capt. Al Haynes (May 24, 1991). "The Crash of United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff. is a set of training procedures for use in environments where human error can have devastating effects. CRM is primarily used for improving aviation safety, and focuses on interpersonal communication, leadership, and decision making in aircraft cockpits. Its founder is David Beaty, a former Royal Air Force and a BOAC pilot who wrote The Human Factor in Aircraft Accidents (1969). Despite the considerable development of electronic aids since then, many principles he developed continue to prove effective.
CRM in the US formally began with a National Transportation Safety Board (NTSB) recommendation written by NTSB Air Safety Investigator and aviation psychologist Alan Diehl"Air Crash Investigation: Focused on Failure", Discover Channel/National Geographic Program "Mayday" S12 E08 during his investigation of the 1978 United Airlines Flight 173 crash. The issues surrounding that crash included a DC-8 crew running out of fuel over Portland, Oregon, while troubleshooting a landing gear problem."United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff.
Following this accident, NASA held a workshop which developed ideas on how CRM might be trained.Cooper, G. E., White, M. D., & Lauber, J. K. (Eds.) 1980. "Resource management on the flightdeck," Proceedings of a NASA/Industry Workshop (NASA CP-2120). It was attended by 70 people from 32 organizations representing 9 countries, with the resulting proceedings described in a following workshop as "the bible" of CRM. In the US, United Airlines was the first airline to launch a comprehensive CRM program, starting in 1981. By the 1990s, CRM had become a global standard.
The term "cockpit resource management" was later amended to "crew resource management" to include all the aircraft crew, rather than just the pilots and engineers as first conceived. The term was coined in 1979 by NASA psychologist John Lauber, who for several years had studied communication processes in cockpits. While retaining a command hierarchy, the concept was intended to foster a less-authoritarian cockpit culture in which co-pilots are encouraged to question captains if they observed them making mistakes.
United Airlines trained their flight attendants to use CRM in conjunction with the pilots to provide another layer of enhanced communication and teamwork. Studies have shown the use of CRM by both work groups reduces communication barriers and problems can be solved more effectively, leading to increased safety. CRM training concepts have been modified for use in a wide range of activities including air traffic control, ship handling, firefighting, and surgery, in which people must make dangerous, time-critical decisions.Diehl, Alan (June, 1994). "Crew Resource Management...It's Not Just for Fliers Anymore". Flying Safety, USAF Safety Agency.
Overview
CRM is the "effective use of all available resources by individuals and crews to safely and effectively accomplish a mission or task, as well as identifying and managing the conditions that lead to error."
CRM training encompasses a wide range of knowledge, skills, and attitudes including communications, situational awareness, problem solving, decision making, and teamwork. Although there is no universal CRM program, airlines usually customize their training to best suit the needs of the organization. The principles of each program are usually closely aligned.
According to the U.S. Navy, there are seven critical CRM skills: Decision making – the use of logic and judgement to make decisions based on available information Assertiveness – willingness to participate and state a given position until convinced by facts that another option is more correct Mission analysis – ability to develop short and long term contingency plans Communication – clear and accurate sending and receiving of information, instructions, commands and useful feedback Leadership – ability to direct and coordinate activities of pilots & crew members Adaptability/flexibility – ability to alter course of action due to changing situations or availability of new information Situational awareness – ability to perceive the environment within time and space, and comprehend its meaning These seven skills comprise the critical foundation for effective aircrew coordination. With the development and use of these core skills, flight crews "highlight the importance of identifying human factors and team dynamics to reduce human errors that lead to aviation mishaps."
Adoption of CRM Since the implementation of CRM circa 1979, following the need for increased research on resource management by NASA, the aviation industry has seen tremendous evolution of the application of CRM training procedures. The application of CRM has been developed in a series of generations: First generation: emphasized individual psychology and testing, where corrections could be made to behavior. Second generation: featured a shift in focus to cockpit group dynamics. Third evolution: diversification of scope and an emphasis on training crews in how they must function both in and out of the cockpit. Fourth generation: CRM integrated procedure into training, allowing organizations to tailor training to their needs. Fifth generation (current): acknowledges that human error is inevitable and provides information to improve safety standards. Today, CRM is implemented through pilot and crew training sessions, simulations, and through interactions with senior ranked personnel and flight instructors such as briefing and debriefing flights. Although it is difficult to measure the success of CRM programs, studies have been conclusive that there is a correlation between CRM programs and better risk management.
The current generic term "crew resource management" (CRM) has been widely adopted but is also known as cockpit resource management; flightdeck resource management; and command, leadership and resource management. When CRM techniques are applied to other arenas, they are sometimes given unique labels, such as maintenance resource management, bridge and engine room resource management (BRM, ERM), or maritime resource management.
Emphasis on non-technical skills CRM is concerned with the cognitive and interpersonal skills needed to manage resources within an organized system rather than 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, skill areas often overlap and are not confined to multi-crew craft or equipment, and relate to single operator equipment or craft.
Aviation organizations including major airlines and military aviation have introduced CRM training for crews. CRM training is now a mandated requirement for commercial pilots working under most regulatory bodies, including the FAA (US) and EASA (Europe). The NOTECHS system is used to evaluate non-technical skills. Following the lead of the commercial airline industry, the US Department of Defense began training its air crews in CRM in the mid 1980s.Diehl, Alan (November 5, 1992) "The Effectiveness of Civil and Military Cockpit Management Training Programs." Flight Safety Foundation, 45th International Air Safety Seminar, Long Beach, CA. The U.S. Air Force and U.S. Navy require all air crew members to receive annual CRM training to reduce human-error-caused mishaps. The U.S. Army has its own version of CRM called Aircrew Coordination Training Enhanced (ACT-E).
Case studies
United Airlines Flight 173
When the crew of United Airlines Flight 173 was making an approach to Portland International Airport on the evening of Dec 28, 1978, 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, and only realized the situation when the engines began flaming out. The aircraft crash-landed in a suburb of Portland, Oregon, over short of the runway. Of the 189 people aboard, two crew members and eight passengers died. The NTSB Safety Recommendation A-79-47 called on the FAA to:
Issue an operations bulletin to all air carrier operations inspectors directing them to urge their assigned operators to ensure that their flight crews are indoctrinated in principles of flight deck resource management, with particular emphasis on the merits of participative management for Captains and assertiveness training for other cockpit crewmembers. (Class II, Priority Action) (A-79-47)
Diehl was assigned to investigate this accident and realized it was similar to several other major airline accidents including the crash of Eastern Air Lines Flight 401NTSB report: Eastern Airlines, Inc, L-1011, N310EA, Miami, Florida, December 29, 1972, NTSB (report number AAR-73/14), June 14, 1973 and the runway collision between Pan Am and KLM Boeing 747s at Tenerife.International Civil Aviation Organization, Circular 153-An/56, Mortreal, Canada, 1978) United Airlines Flight 232
Captain Al Haynes, pilot of United Airlines Flight 232, credits CRM as being one of the factors that saved his own life, and many others, in the Sioux City, Iowa crash of July 1989:
Air France 447
One analysis blames failure to follow proper CRM procedures as being a contributing factor that led to the 2009 fatal crash into the Atlantic Ocean of Air France Flight 447 from Rio de Janeiro to Paris. The final report concluded the aircraft crashed after temporary inconsistencies between the airspeed measurements—likely due to the aircraft's pitot tubes being obstructed by ice crystals—caused the autopilot to disconnect, after which the crew reacted incorrectly, causing the aircraft to enter an aerodynamic stall from which it did not recover.
Following recovery of the black box two years later, independent analyses were published before and after the official report was issued by the BEA, France's air safety board. One was a French report in the book "Erreurs de Pilotage" written by Jean-Pierre Otelli, which leaked the final minutes of recorded cockpit conversation. According to Popular Mechanics, which examined the cockpit conversation just before the crash:
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 (CTSB) determined a failure of crew resource management was largely responsible for the crash of First Air Flight 6560, a Boeing 737-200, in Resolute, Nunavut, on August 20, 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 but a 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.