WARNING!!! This is for ERAU — Wildinger’s class. Don’t even *think* of using this in his class!!! -strong message follows- Crew Resource Management 1
Running Head: CRM AND AVIATION SAFETY
Crew Resource Management and Aviation Safety
Steven B. McSwain
Embry-Riddle Aeronautical University
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Throughout the history of aviation, accidents have and will continue to occur. With the introduction of larger and more complex aircraft, the number of humans required to operate these complex machines has increased as well as, some say, the probability of human error. There are studies upon studies of aircraft accidents and incidents resulting from breakdowns in crew coordination and, more specifically, crew communication. These topics are the driving force behind crew resource management. This paper will attempt to present the concept of crew resource management (CRM) and its impact on aviation safety in modern commercial and military aviation. The concept is not a new one, but is continually evolving and can even include non-human elements such as computer-controlled limitations on aircraft maneuvers and the conflicts that result in the airline industry.
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Crew Resource Management and Aviation Safety
Since the birth of aviation, man has been tasked with operating aircraft safely, yet effectively. From the beginning days of being able to simply operate an aircraft without injury for seconds at a time, to today’s issues with safety in supersonic international travel, crew resource management has been with us in some from the beginning. The term CRM began to spread in the 1980’s among the major airlines, fueled by industry and university research into human factors. The U.S. military has also taken a very active in the development of CRM techniques to aid in the high stress environment of military aviation.
The basic concept of crew resource management (CRM) is to train crewmembers to use all available personnel, equipment, and experience to safely and effectively operate an aircraft. It is used in nearly every facet of aviation from the smallest regional airline, to the largest major carrier, to the various crew operated military aircraft. One aspect of aviation missing from the fold is the general aviation (GA) community, such as the private pilot. This has become a growing concern as many future air carrier pilots and military pilots begin as private pilots. The need for CRM training in this area is there, but the training seems excessive and useless to many in the field as most of these pilots operate single pilot aircraft. Perhaps this attitude comes from the term crew and is dismissed by the private pilot. This can be a dangerous attitude, as there is no doubt that sound decision making and the use of available resources should be a priority at any level of aviation
Terms and Concepts Used in Crew Resource Management
In order to effectively explain the concept of CRM and its role in aviation safety, it is necessary to have at least a limited understanding of common terms and phrases. One of the two key elements of CRM is situational awareness, or, SA. Simply put, it is the understanding of
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the conditions surrounding your flight. Knowing what is happening, what has happened in the past and how that may affect your flight in the future. Situational awareness is probably best described as a conditioned state of mind while flying. It comes from experience and knowledge and can be blocked by being unfit to fly do to fatigue, for example. This concept is obviously a major consideration in flying all aircraft, but can be considered to be somewhat easier maintained in a crew aircraft than in a single pilot one.
Another key concept in CRM is communication. This is a topic best described in it’s own publication, as there are numerous factors that contribute to successful or failed communication. There are many factors to be considered when analyzing communication in the context of CRM, such as dialect. English is the universal air traffic language, yet it would be impossible to regulate accents and intelligibility of an air traffic controller or aircraft crew. This can obviously lead to missed communication between an American flight crew and Egyptian control facility, for example. Another aspect of the communication problem can be attributed to seniority in civilian aviation, or rank in military aviation. This barrier, fear of communication, must be overcome in order for a flight to safely operate. Each crewmember should be able to make input to the flight without fear of reprimand. Each person should provide feedback and be willing to accept a suggestion from other crewmembers. The last subject I will cover in regard to communication is standardization. Procedures – checklists, operating instruction, and technical orders – are written in a standardized form to avoid confusion and establish a common language. This usually results in a barrier of communication in more experienced crewmembers. They can be so accustomed to the operating procedures that they expect everyone else to have the same level of understanding. This, combined with their usage of nonstandard verbiage can lead to deadly miscommunication in a worst-case scenario.
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A third commonly referred to concept in crew resource management is available resources. This can mean internal or external resources. Internal resources are things such as experience and knowledge, and having one does not necessarily require having the other. A crewmember can be experienced but not have a great deal of aircraft systems knowledge. Such as when in the military, as often happens, a pilot is transferred late in his or her career to another aircraft. That pilot may have over five thousand hours of flying experience, and even several hundred hours of combat flying experience. However, when arriving at a new assignment they have a very limited amount of aircraft systems knowledge in the new aircraft. This is also true for a civilian air carrier pilot who changes aircraft at some point in their career. External resources can consist of checklists or operating instructions, for example. This is an equally important factor in aviation safety, as can be seen by the report on the American Airlines crash in Columbia (Simmon, 1998). The failure to abide by these resources can have disastrous results. Many things can contribute to the breakdown in this area, most evident is fatigue combined with a high level of experience. An experienced captain can rely too much on knowledge and not enough on published procedure and guidance.
This summary of key concepts is not meant to be an all-inclusive list, but a brief familiarization of the terms and ideas commonly referred to in the subject of crew resource management. There are many other important factors, but I believe a basic understanding of these listed is required to gain an understanding in the basics of CRM.
Impact of Crew Resource Management in Safety
There are countless case studies published by the National Transportation Safety Board (NTSB) revealing CRM-related causes of accidents. One such example is the American Airlines
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flight 965, a Boeing 757 that crashed into terrain while making an approach into a Columbian airport in 1995. The crew made several mistakes, including exhibiting get-there-it is, a condition in which the crew is determined to perform an act, whether it is departure or landing, due to fatigue or some other outside motivation. This lapse in judgment caused the death of all but four of the 163 passengers and crew on board. This lead to compounding problems, such as missed and erroneous procedures. There were checklist items either omitted or improperly performed, as well as communication breakdowns with air traffic control (Simmon, 1998, p. 1-8). In this tragedy are multiple examples of breakdowns in crew resource management. All the tools necessary for a safe completion of the flight were there but the crew failed to utilize them.
Another factor to be considered in the crew-operated aircraft is the authority gradient (Hawkins, 1987, p. 36). This is easily described as the who’s the boss? factor. The most ideal situation would be a captain or aircraft commander with a wealth of knowledge and experience combined with a first officer or copilot with somewhat less, working as a team. All too often, however, an overbearing or dominant captain is placed with a timid or unassertive first officer, or a highly experienced and equally assertive pilot in each seat. This can lead to a multitude of problems, as evident in the Tenerife accident. In that case, the less confident first officer’s questions regarding takeoff clearance were totally dismissed by the command pilot. Although the example I gave was in regard to a major air carrier, it is easy to see how this could be a problem more present in the military aviation community.
The military by nature is rank structured and can lead to an improper crew relationship in the aircraft. A perfect example is the crew of the USAF’s AC-130U gunship. With a tactical crew of at least thirteen, CRM is a very real issue in every day operations. AS a crewmember on this aircraft, I have seen countless examples of this process at it’s finest as well as it’s worst. It does take training and experience for a senior officer acting as aircraft commander to take inputs and
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recommendations from a brand new junior enlisted crewmember. Yet through an effective training regimen, the authority gradient can be groomed to its proper level. To be an effective crew, all crewmembers regardless of military or civilian must display the ability to lead and follow.
The key to safe flight, and the driving force behind crew resource management training is problem solving. Civilian and military alike have simulators and training regimens to aid in the development of problem solving skills. These training aides proved a solid base of information and procedure, and help to develop good problem solving techniques. However, the great Catch 22 of aviation is that good practical skills come from experience. This is where CRM takes it’s place in flight safety. It is up to the crew of an aircraft to help less experienced crewmembers to gain this experience when problems arise. This is where the factors of CRM I talked about earlier come into play. The less experienced crewmember, though trained to standards and expected to perform all duties, will rely on communication and the more developed situational awareness of his or her crew to gain that experience. This cycle should repeat itself, continuing to provide new crewmembers with the experience and skills necessary for safe flight. CRM training has been put in place to overcome the barriers to this process in the crew environment. The only aspect of aviation that seems to be the exception is general aviation, as mentioned before.
General aviation, or GA, is severely behind in the development of CRM training. As a private pilot, I have noticed the absence of this training. After first being trained as a military crewmember, I noticed immediately the lack of CRM in any aspect of the training of the private pilot. Perhaps the reason I noticed this problem is the same reason many private pilots do not notice it. They have no experience, through no fault of their own, with the crew environment and it’s challenges and benefits. Though there is a small percentage of private pilots who will
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never operate in the crew environment, the majority begin this training as a step to a career in aviation, or at least to the point of flying with other people. Many are future small business pilots, many are future military pilots, and a few are future air carrier pilots. I personally used private pilot training to help prepare me for a career as a military pilot, but my situation was unique as I stated before. The development of CRM in GA is beginning to be addressed, but is years behind that of commercial and military aviation. This is evident by the lack of continuity and availability of literature on GA crew resource management training (Santiago, 1996).
Crew resource management training is no doubt a vital part of flight safety. The programs have developed from crude briefings to sophisticated simulators and training techniques. The examples of the importance of this training can be found in almost every NTSB report of an incident involving the human factor of flight. I have attempted to bring to light the more important aspects of crew resource management, though the concept is much broader than I have presented. The basics of communication and problem solving are still the keys of CRM, and still seem to be the cause of most aviation accidents. The programs in effect to combat this problem are under constant development and analysis, in a hope to avoid these situations. The civilian industry continues to lead in development due to commercialization, with the military not far behind. The only real deficiency in CRM program development seems to be the area of general aviation as described earlier. Until this problem is addressed, there will still be a glaring weakness in the general area of aviation safety. However, with the rate of technology increase and cheaper methods of instruction, we should begin to see this problem addressed in the near future. Until then, aviation will rely on civil commercial aviation the military to continue research and program development for the years to come, hopefully resulting in an increasingly safe method of travel and recreation.
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Hawkins, Frank H. (1987). Human Factors in Flight, 2nd ed., 35, 36.
Santiago, Marco Jr. (1996). Application of Crew Resource Management and Line Oriented Flight Training Concepts to General Aviation Flight Training. Arizona State University.
Simmon, David A. (1998). Boeing 757 CFIT Accident at Cali, Columbia, Becomes Focus of Lessons Learned. Flight Safety Digest,