Crew Resource Management. What is it and why you should care.

Crew Resource Management or CRM is multi part system that is designed to mitigate human errors. It was born out of the 1977 Tenerife disaster and a 1978 United airlines crash. In both incident had the crews used CRM processes and techniques the accidents in all likely hood could have been prevented. NASA was instrumental in developing CRM and the culture of safety it ensures. Recently in the aviation forum there are a few instances we are discussing where crews ignored CRM and disasters almost ensued. So lets take a quick look at what involved.

If you look at an aviation disaster there is frequently a distinct chain of events. If at anytime a crew member had spoken up of pointed out the issue, the chain of events could have been broken.

CRM is not about an individuals skill in performing a task or say operating a particular piece of equipment. It is rather a principle of communication, and empowerment for those to speak up if they are uncomfortable.

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. en.wikipedia.org...

This principle can also be applied to not only aviation, but many other fields.

As the Team Leader of a Pediatric Critical Care Transport Team, I am often leading a team that can comprise up to 7 people. I am the final medical authority in most cases. But we practice CRM. Its impossible to know everything and If I miss something ITS essential that other crew members from our basic EMT's on up feel the environment is a safe one to voice concerns. I as the leader need to be open to having my decisions questioned. This is not about my ego this about safety. Be it a medical issue or a safety one I depend on my team as much as they depend on my. After stabilizing and packaging we ALWAYS do a brief summary of the patient, I go over emergency plans, assign roles, and ask if there are any unresolved concerns. We also do this in the pre arrival brief.

Another example. on 12/30 we hopped from Moffett Field to Santa Monica. As we were approaching the LA Area, the TCAS made the loud announcement 'Traffic Traffic". All conversation ceased immediately (we went into "sterile cockpit" which means no talking unless safety related) , eyes out and we searched till we could ID the traffic. Once identified and the traffic shifted locations we each would call when when we had eyes on or off until it was no factor.

The TCAS readout


That was a prime example of CRM in an active airspace.

That was a really good read and very informative

The small white blur in the upper right 1/4 gives you an idea of how we all have to work together to spot this stuff. The quality is poor because it was super hazy and the auto focus has a hard time with the dual pane windows

I believe CRM was touted as one of the success factors in the Sullenberger controlled crash into the Hudson where everyone survived.

originally posted by: schuyler
I believe CRM was touted as one of the success factors in the Sullenberger controlled crash into the Hudson where everyone survived.

It was and if you listen to the cockpit tapes its ongoing through the entire incident including the flight attendants who managed the evacuation etc.

Thats why I find it so appalling that crews are starting to ignore it in the air. Its simple and it works

a reply to: FredT

Some of it is culture. The majority of the recent incidents involve cultures where you simply don't do anything to embarrass someone that is considered your superior or older than you. It's hard to get through to people that it's better to point out an error, then become a crater in the ground.

Some of it is "what the hell does he know, he's only been flying for x hours". I've been seeing a lot of "why should I teach them, that's what their school was for" attitude from ramp guys lately, along with pointing out errors for people to laugh at. It's becoming prevalent in more than cockpits.

a reply to: FredT

Great post Fred and something that is near (and dear) to plying my trade.

Aviation incidents/accidents are a bit like a sine wave in that there are peaks and troughs. We seem to be coming to a peak at the moment and from what I have been reading and have seen personally, this upward trend is set to continue. The prevalence of junior/inexperienced crews (due to the huge increase in demand for both Tech and Cabin crew) and too many "she'll be right mate" attitudes are starting to become prevalent again both in the cockpit, in the maintenance organisations and as Zaphod alluded to; on the ramp.

CRM and Safety go hand-in-hand and unfortunately safety is seen as an embuggerance factor for a lot of aviation organisations due in no small part to Zero based safety programs (ie. Target Zero, Towards Zero etc.) that have been imposed on a lot of the industry due to its affiliation with the resources sector (ie. Oil and Gas industry - and what a fantastic safety record they have............ NOT!!) One of my favourite memories was sitting at an aviation safety conference listening to a very reputable presenter giving a presentation on Zero based safety programs. In front of a full auditorium that included various industry CEO's (aviation, resource and safety) and their accompanying representatives, the presenter stated:

"Zero based safety programs are neither inspirational nor aspirational and just provide an organisation with something to hide behind"

Never has a truer statement been made!

Sorry for getting a little off topic however, as I said this is what I do for a living and when I see instances like the Air Canada SFO incident, which is one of many avoidable incidents that are being reported throughout the industry; I cringe - especially when I talk to an ex safety employee of a huge international operator who related instances of staff being berated for reporting safety occurrences happening in the cockpit.

a reply to: Gurumuka

There was an incident a couple years ago where an Allegiant MD-80 made an emergency landing (I know, shocking ain't it) for smoke in the cabin. The Captain made the decision to evacuate and had the flight attendants pop the slides after they stopped, when smoke was reported coming from one engine.

A month and a half later he was fired. The airline said he "ordered an evacuation that was entirely unwarranted and ... compromised the safety of your crew and your passengers and led directly to the injuries."

It's cropping up in the military too. There was a unit a couple months ago where a crew pulled themselves out of the rotation because the AC didn't feel he was up to the flight. They later found a nasty message written on the crew rotation board about certain crews being lazy.

a reply to: FredT

Thanks FT. A good example of putting our personal egos on hold, while we care for the safety of others, well: our-self included in this case.
-
Surely as a species: we can do better, in taking care of those whom need us, to care for them?

a reply to: Zaphod58

Wow, I hadn't heard of either of these incidents.

The fact that they fired a pilot for that split second decision is unconscionable. Do a little research on "Just Culture" and you'll see how this type of disciplinary action will ensure the next event that occurs will damage both the aircraft more than it should have, as well as involve loss of life. When aircrew are punished, instead of educated, during events like that, it makes their decision making process more complex, slower and riskier.

During one of my deployments to the Persian Gulf, we split duties with another aircraft carrier in the gulf. We basically took 12 hours and they took the other 12 hours. We drew the bad 12 hours, as our first flights started around midnight and ended around noon. Needless to say, the flip-flopping of our circadian rhythms didn't happen smoothly. At about day 5 or 6, one of my colleagues, a pilot, pulled himself off the flight schedule. It made it harder for the rest of us, but we were indoctrinated to ensure that we evaluated our self for our capability to fly. His evaluation was that he was unsafe. This is better for everyone, but still hard to make up for. The idea that someone would take the time write their grievances with this is ludicrous. I suppose a dead, tired pilot is better in his/her mind than a gap on the schedule.

As a Human Factors teacher, I am nervous that the safety culture is not as strong as it should be in many airlines.

a reply to: cosmania

That flipping of the circadian rhythm is what caused several of the F-117 crashes. They would fly at night all week, go home for the weekend and do things with their family, come back and fly Monday night. It cost at least one pilot.

Safety is becoming a joke anymore. My father started my training at a very early age. The two things he hammered hardest into me were safety, and safety,followed by, if you aren't willing to do it, don't ask anyone else to do it (and yes, he really did believe that. He walked 3-4 miles, in his blues, on a comm cord, next to an aircraft on tow with a missing nose wheel.)

It used to be, you'd get an attaboy for taking yourself off rotation, because it meant you were being smart. Now, you're lucky you're not written up or made a maintenance officer.

originally posted by: Zaphod58
It's becoming prevalent in more than cockpits.

You have that right. The company that I work for is comprised of two groups. One is the creative part and the other is the manufacturing part. The creative group is made up of the younger crowd. You know the ones that think how close you work to Google is prestige. We are starting to get some of the snowflake crowd in this group.
I'm in the other group, the manufacturing group. Part of my job is to sometimes say "No." to some of the things that the creative group come up with. I'm not doing it to be a jerk, I'm doing it because of things like Building Codes, Electrical Codes, UL certification, the Laws of Physics and other things like cost targets.
Some of the snowflakes got the bright idea that if they didn't invite me to the meeting, I couldn't say "No". After a few incidents that cost the company a lot of money, it became mandatory that I be at the meetings.
I can only see this getting worse when the "safe space" crowd finished college and meets the real world.

As a flight engineer I was routinely the only FE scheduled so If I did not go for any reason the flight was canxed and I ended up having to explain to the commander why I felt I could not go. So there was a lot of pressure to never admit how tired/sick you really were.

Yet the rest of the crew was typically 2 deep for each position and on a regular basis I saw guys and gals not go because they were hung over with zero repercussions.

Ive seen the same type of thinking drift into the maintenance side of things, "we really need this plane to make the afternoon go, write up that problem for a check after flight." Even though everyone involved knew the part was already bad.

I used to love flying, not so much anymore just do not like what I am seeing.

We are seeing this play out with our EMT's. If they call out because they are too tired, they get fired. If they fall asleep during a ground run, they get fired.

So they feel (being invincible 18-22 year olds mostly) that they ZERO incentive to call out.

Even the 'IMSAFE" algorithm involves personal honesty.

We haven't seen it in the air yet. Its not an airliner so we are ALL on comms, and we all are talking.

a reply to: Irishhaf

I started seeing it begin to creep into maintenance in the 90s. Nowhere near as bad as now, but every so often there would be a write up that just would not cooperate. Someone would come along and offer the solution and if it was close enough, it became "no, we'll find it after the upcoming trip".

Lately it's been a lot worse, even from the outside looking in. I can't imagine some of the stuff I don't see. The training lately is atrocious, even fresh from school. I see pictures of safety wire jobs done by someone that's supposed to be just out of school, that use about 4 times as much wire as they should, with no tail, and wired to something it's not supposed to be wired to. And the unit guys only sit there laughing and taking pictures so they can laugh at them on social media. "Not My Problem" is becoming the norm, not the exception.

a reply to: Zaphod58


Yup my wife is getting out of her flying job in a few months and I am ecstatic over that, it is only a matter of time before something bad happens.

I will admit I have let somethings fly but it was after conferring with more experienced maintainers, and consulting the crew to verify it was not a safety of flight issue for both groups and that crew was comfortable with the decision.

What I am seeing now they are making choices based on the MC rate, and there is little to no information being passed back and forth between maintenance and ops.

a reply to: JIMC5499

I can't wait to see that. It should be scarily amusing to watch.

a reply to: Zaphod58

It is scary now. Had a clown alter a set of drawings in Adobe so that he could bypass Engineering and increase his margin for a bonus. $16,000 in damage later, policy is changed so that Engineering has to be at every meeting. You can't hang four 75 lb. signs from a drop ceiling.

a reply to: JIMC5499

Good god. I knew things were getting bad, but jesus that's taking it to a whole new level. Anything for a buck.

Reminds me of a Greenacre 747 cargo conversion I saw at Mascot.Crew had a leaking hyd line one one the engines..Meh keep topping up the tank at each port of call.Bozian probably remembers that one,late 80,s.