Aviation has come a long way since the days of the Wright Brothers experimenting in the sand dunes of North Carolina. According to the FAA, there are over 45,000 flights every day, which equates to 16.4 million flights a year that they supervise (2021). This is a ginormous responsibility to ensure a safe and efficient form of transportation on the sky’s highways.
To do this, immense trust is bestowed upon the aircrews that make these flights happen. These aircrews have a significant number of tasks that they must stay on top of to get from points A to B safely, which requires the utilization of the right tools and teamwork. One of the most important and effective tools used is crew resource management.
What Is Crew Resource Management?
Crew Resource Management or CRM is defined as the effective identification, direction, control, and utilization of all available resources to maximize flight safety, efficiency, and reduce error.
The FAA has a similar definition, which they define as the attempt to improve human’s ability to perform work using complex machinery while simultaneously creating a safe flying environment (FAA, 2012).
These definitions are specific but ambiguous at the same time, but the two words that are highlighted are safety and efficiency, which are the goals of proper CRM training.
In essence, CRM is the management of the risk of human error.
CRM History and Background
Lesson in bad CRM
On December 29, 1972, a Lockheed L-1011 A.K.A Tristar operated by Eastern Airlines was on final approach preparing to land in Miami. As they attempted to configure the aircraft for landing, they realized that their nose gear green light indicator that tells the crew that their nose gear is fully extended and locked failed to illuminate. Immediately, the Captain attempted to recycle the gear by putting the gear lever up then down, but with no success. The first officer at the time was the pilot flying, so the captain instructed him to engage the autopilot, which he acknowledged. After doing so, the First Officer removed the light lens assembly but jammed it when attempting to replace it. While both pilots were attempting to fix the issue, the captain then sent the Second Officer below to check if the nose gear went down visually. As the Second Officer went below, there was an aural warning in the cockpit which indicated a deviation from their assigned altitude, but neither pilot recognized nor made a change to the aircraft. MIA approach control then queried the aircraft because they had descended to an altitude of 900 feet, which was 1,100 feet below their assigned. The captain then responded to the controller but did not recognize the altitude deviation until the First Officer commented that “they did something to the altitude”. At this moment they were in a turn and started to receive radio altimeter warnings, but it was too late, and the aircraft crashed 19 miles from the airport. The mishap resulted in the destruction of the aircraft and 101 fatalities.
Immediately, the National Transportation Safety Board (NTSB) went to work. How could a commercial aircraft with an experienced crew and multiple crewmembers in the cockpit have a mishap such as this? After gathering the materials and analyzing the data from the recordings, the NTSB determined that the probable cause of this accident was the failure of the flight crew to monitor the flight instruments during the final 4 minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of, the nose landing gear position indicating system distracted crew’s attention from the instruments and allowed the descent to go unnoticed (Accident Report NTSB-AAR-73-14, 1972) In other words, human error. This mishap was completely avoidable and served as one of the catalysts for the industry to address the most common cause of aviation related accidents at the time, human error.
We keep seeing the terms human factors and error, but what do they even mean? The FAA defines human factors as a “multidisciplinary effort to generate and compile information about human information capabilities and limitations and apply that information to equipment, systems, procedures, jobs, environments, training, staffing, and personnel management for safe, comfortable, and effective human performance” (FAA, n.d.). The FAA understood that to develop an effective crew concept, they must fully understand human factors. This was highlighted because at the time, human factors/human error were found to be the cause of 70% of all mishaps (FAA, 2012). For this reason, studying human factors and how they pertain to aviation became a priority. This push to become more knowledgeable on the subject resulted in what we know today as Crew Resource Management or CRM for short. In the 1970’s when the crew concept was first coming online, the goal was for crews to become safer and more efficient, despite the potential of human error. Now that we have discussed the need to address human factors, for one to have a better understanding of CRM they must also know its history.
In 1972, the SHELL model was developed to describe the interrelationship between human factors and the aviation environment (Taslimi, 2021). The model was designed to look for productive processes in the interactions between the components of software, hardware, environment, and liveware. These four components interact with the middle liveware or human component to offer areas for human factors assessment and understanding. As aviation continued to evolve and become more complex, so did the model which adapted with new layers due to more intricate cockpit designs, instrumentation, checklists, etc.
In 1974, the aviation safety pioneer Frank Bird endorsed the Domino Theory for aviation, which stated that a series of errors can lead to a mishap (FAA, 2012). If a single domino falls over, it’ll knock over the rest, but if a domino gets removed from the line, it will prevent the remainder from toppling. In essence, if an unsafe act or condition could be removed from happening then there is a lot smaller of a chance for a mishap to take place. This theory was later used as a model and expanded on to create what we use today.
In 1979, the National Aeronautics and Space Administration (NASA) hosted an industrial workshop which led to the foundation of aviation psychology in CRM (NASA, 1980). This was significant because NASA brought in representation from the biggest airlines and experts from a variety of fields and backgrounds including doctors, psychologists, engineers, and pilots in the interest of aviation safety. This led to a concern amongst the pilots who originally believed that they were losing control to those who never flew, but over the duration of the workshop they came to realize that they were learning how to manage the systems and workload more efficiently.
In 1990, British psychologist James Reason expanded and updated the Domino Theory by introducing the Swiss Cheese Model, which described four levels of human error, each level influencing the next (Shappell et al., 2000). This approach to human error became popular amongst the aviation community and in particular the accident investigation group. This model was further expanded by Doctors Shappell and Weigmann who designed the Human Factors Analysis and Classification System (HFACS). The HFACS examines how aviation problems are developed. It uses a four-tiered approach to demonstrate how accidents occur, whether they are skill based, perceptual, or attributed to organizational factors (HFACS Inc, n.d.) The HFACS provides insight into how human error occurs in aviation.
Early iterations of CRM began with cockpit resource management. The focus was only on the cockpit, but the crew concept later incorporated other liveware operational areas that affect the flight profile such as flight attendants, maintenance, etc. CRM continued to develop and adapt to new considerations and with the use of communication, prioritization, and workload management, the backbone of crew resource management was created and led to what we know and practice today.
Who Uses CRM?
Who can practice the utilization of CRM? A big percentage of the CRM process for a single flight is the cockpit portion, but according to the FAA, an effective CRM process includes all personnel that works and coordinates with the cockpit crew (2004). This includes any person involved in the decision-making process required to operate a flight safely. This can include ATC, maintenance, dispatchers, etc.
It is important to realize that CRM is also not limited to crew-type aircraft or crews.
Single-pilot resource management (SRM) was developed to incorporate the safety practices and efficiencies that crews were using and applied them to single-pilot environments. This was possible because many of the same aspects of flying with a crew also apply to single-pilot flying.
SRM training focuses on utilizing the environment and the tools available such as automation to enhance situational awareness and decision making. This is crucial since single pilots are still required to do everything a crew aircraft is required to do, but with fewer brains to do it.
Now that we have a big picture understanding of the purpose of crew resource management in aviation, it is time to get into the specifics. To meet the intent of CRM which is safety and efficiency, it is imperative that pilots and the crew are technically competent.
The FAA AC order 120-51 E breaks down three clusters on the parts of technical competency (FAA, 2004). Motor Skills are the first which interpretations of hazards and system controls are examples. The second is procedural skills which involve such items as emergency procedures, flight maneuvers, and abnormal occurrences. Lastly, is the information-based knowledge cluster which includes organizational policies, laws or rules, security, and hazardous materials.
For an aircrew member to be an effective CRM steward, they must be technically sound in their position. This is the reason why pilots learn how to fly the plane before they learn conflict resolution. Not knowing how to land is much more dangerous than subpar team-building skills. Once a crewmember is technically proficient in their position it is then when CRM skills are honed in.
CRM Training Programs
Regulatory agencies around the world including the FAA and European equivalents require CRM training for commercial crew members and professional aviators. This has bled into other areas of the aviation community who often time voluntarily create CRM programs to promote safety and efficiency in their own organizations.
For example, the United States Air Force and the United States Navy have their own versions that aircrew members are required to stay current on, which are designed to help identify hazards and manage threats to stay safe and effective in operational environments.
Each CRM program is tailored for the specific user of the skills. United Airlines will approach the subject differently from the army, simply because each organization has two different objectives. These programs can vary due to aircrew, aircraft type, financial restraints, the culture of the user of training, and even due to the course developer.
Regardless of the differences, each program requires the same elements to be successful. These elements are the necessity for everyone to be on board, top-down, and bottom-up styled integration, and proper tailoring to meet the goals of the organization (FAA, 2012). Commitment throughout the organization to such a program is key.
The FAA provided guidelines for the development of such programs in their AC 120-15E. This document helps provide a starting point for organizations to implement, reinforce, and assess CRM for crewmembers that the association comprises.
Components of the CRM training include initial indoctrination, recurrent practice and feedback, and finally continual reinforcement.
Components Of CRM Training
Initial indoctrination and awareness are considered the first step for any training program. The sole purpose is to orient the students/audience to a starting point. This is typically done through classroom instruction, discussions, and CRM videos. In these sessions basic concepts of CRM which we will talk about more in depth later are explored and defined.
Students learn what CRM comprises of and examples of good and bad CRM practices. This component is essential because it provides the backbone and foundation to the remainder of the training by putting everyone on the same page. Experience has shown that instilling CRM skills early at the beginning of a crewmember’s career will allow them to effectively build their skills throughout their aviation life.
An integral part of any habit pattern or skill gain is consistent practice and subsequently feedback. In the airline operator world, this is through programs such as LOFT and simulators. In the Air Force world, this is through simulators, missions, and tabletop exercises such as stand-up where pilots are provided a situation and must solve it with their technical knowledge and CRM skills.
Feedback is very effective in helping the crewmember understand how they may improve and what areas they are doing well in. In many aviation communities, debriefs are as long, if not longer than the flights themselves because learning from mistakes in a safe environment is invaluable.
Continual reinforcement is done by integrating CRM into the culture of an organization. If there is a cognizant focus on safety and subsequently CRM, then the organization will flourish. One-time training is simply not effective for building strong skills and habits which require repetition and practice and the appropriate feedback.
This is especially true for individuals who are set in their ways or have not had the chance to work in a crew environment. This is evident in single-seat mentality pilots who transfer over to a crew-based aircraft.
A pilot may have all the technical skills in the world, but if they cannot work well in a crew environment the cockpit is inherently not as safe as it could be. This is the purpose of the continual reinforcement of CRM skills.
CRM Concepts and Topics
To manage human error, all CRM programs develop curricula on basic CRM topics and how they affect the safety of flight and applications to their organization. These concepts include mission analysis, situational awareness, communication, flexibility, decision making, assertiveness, and leadership. When crew members start their training, their skills in the concepts previously mentioned are most likely low but learning what each means and the goal of each paints the picture for proper CRM which will allow them to move on to add more advanced CRM topics.
Mission analysis includes all three stages of a flight: pre, during, and post. Prior to a flight, a good game plan and mission planning are essential for a successful flight. For the E-3, there are up to 40 crew members that all need to be on the same page which requires an extensive mission planning process and many meetings. During the mission, an effective crew member is one that is present and focused on what is happening in front of them such as their instruments and what they will need to do in the future to keep the flight on track. After the engines are shut down, the next phase requires a good debrief. Debriefing is an art and there are many techniques, but the importance lies in finding mistakes, learning from them, learning how to prevent them in the future, and pointing out good portions of the flight for positive reinforcement of good habits/skills.
Situational awareness (SA) is a skill that separates average crew members from great ones. The skill is invaluable in the aviation community. Crewmembers are responsible for multiple tasks at once but are required to track them all. Combine this with other external factors such as weather, other traffic, limited fuel, all of it quickly adds up. Someone with a good level of SA can organize their thoughts, keep track of what is in front of them and around them, and understand how present conditions will affect the crew in the future. SA is most effectively gained through experience. One can give themselves more SA by effectively mission planning, but only to a certain extent. SA is often regarded as the most important factor for safety.
Communication is simple enough but often misjudged. It works in three parts: a message is sent, it is then received and interpreted, and finally, the receiver provides feedback to the original sender. Each part provides a chance for there to be a form of miscommunication. This is exacerbated in the aviation environment. Communication can be one of the tougher skills to learn for individuals due to the unique aspects that aviation requires in the communication department. There can be 30 individuals on the same radio frequency all trying to communicate effectively, and if you do not know the sequence, jargon, or what to listen for you can put not only your crew but other crews at risk. This is not limited to working with external agencies such as ATC, but also being able to effectively communicate with other crew members effectively is crucial. Building communication skills requires practicing active listening skills, learning industry-specific verbiage, and providing feedback.
Flexibility. We often hear that the best plans do not survive the first shot. This is true with any flight as well. Despite crewmembers’ best efforts to plan everything perfectly, we cannot control external factors which require crewmembers to be flexible. As the Air Force likes to say, flexibility is the key to airpower. Crews need to be able to adapt and overcome changes to give themselves the best chance for success and safety. Changes to plans are daunting to those who do not have experience but building the flexibility skill makes a crew member a much more valuable teammate.
Decision-making may be self-explanatory, but it is an important topic. Crewmembers need to have the ability to determine and take a course of action based on the information that they have available to them. Lack of decision-making and hesitation can be risky for everyone. Every crew member has a role to play each flight and may be expected to make decisions autonomously that affect others, having the courage and ability to do such that is important in an aviation environment.
Assertiveness could be an extension of decision-making. It goes along the lines of having the courage to make important decisions despite adversity. An effective crew is one that can confidently work together and back each other up or call each other out. Lack of assertiveness is what has gotten crews killed in the past with reliance on luck or completely giving up control to other crewmembers. An unfortunate example of this would be the 1994 B-52 mishap at Fairchild AFB. In this mishap, the crew failed to stop the aggressive pilot from performing a steep turn at 250 feet after a go-around which resulted in a stall and 4 fatalities (TheFlightChannel, 2021).
Leadership is last on our list but plays a major role in the overall CRM goal. Leadership in the big picture is what continues to allow CRM to advance forward. It is the ability for the crew member, crew, or organization to influence and guide others so they too can practice proper CRM. Experience is a valuable commodity among the aviation community and one that not everyone has had the chance to accumulate so it is on those who do have that experience to help mentor those who do not. Leadership and mentorship foster the safety and CRM culture that these programs strive to create.
By focusing on developing these skills and concepts, organizations are helping to make the skies safer for everyone. As mentioned previously, these organizations will take these concepts and build upon them for more advanced CRM topics which can be broken down into four clusters. These topics include communications processes and decision behavior, team building and maintenance, workload management and situational awareness, and finally individual factors and stress reduction.
Communications processes and decision behavior training aims to tear down communication barriers such as rank and age by highlighting the importance of clear communication. These topics provide training on establishing and maintaining open communication flows, recognizing the value of multiple courses of action, crew feedback, effective techniques for resolving disputes, and cognitive factors that affect decision making. It looks at external and internal factors that will affect the flow of communication between crews and how to overcome or utilize them effectively.
A crew is a team, and in the team building and maintenance, the goal of the training is to push that point across. An individual is just one part of a whole. Derrick Henry of the Tennessee Titans would not be able to do what he does without his O-line, and the same principle is applied in this aviation context. Training in these topics helps crewmembers to benefits from coordination, the balance of authority and assertiveness, and group dynamics and how it could apply to respective positions. This cluster also dives into the importance of having a relaxed and friendly but task-oriented mindset in the aircraft.
We mentioned previously that situational awareness is often regarded as one of the biggest factors when it comes to flight safety. In this cluster of workload management and situational awareness, the training aims to show the importance of planning, prioritization and avoiding distractions to gain more SA. This is fundamental in CRM, which utilizes all resources effectively to make flying safer and more efficient. Workload management is essential to making that happen. A crew must allocate tasks appropriately and in a logical order based on the situation. This training attempts to engrain the use of standard operating procedures (SOPs), the use of checklists, and learn what should be prioritized. For pilots in an emergency, it has been pounded into our heads to aviate, navigate, then and only then communicate in that order. Fly the plane so you do not crash, make sure you are going in a safe direction away from the ground, then talk on the radios. This order is prioritized in that way for safety.
Though we often see Tik Tok and Instagram reels of people taking their Cessna into a majestic sunset with EDM music, it on the contrary can be very stressful. Anyone who has experienced a check ride or evaluation ride can attest to the amount of sweat they left on the stick/yoke due to sheer terror and anxiety. The individual factors and stress reduction topics explore the negative effects of stress fatigue have on the human body, cognitive function, and performance. Its further dives into how these items can negatively affect the crew and ways to mitigate these risks.
Successful CRM Program Example
A successful program requires the organization to assess their crew members to the standards that their CRM program establishes. This is often time done through testing or tied into evaluations such as check rides for pilots. For example, the U.S. Air Force pilots will get graded on their CRM performance and can fail rides for a lack of demonstration of good CRM skills. This provides a way to quantify how an organization is doing as a whole and helps provide insight into areas that may need improvement. Now that we have seen how CRM is useful in making the skies safer, let us explore an example of an actual CRM program.
The Air Force CRM program is outlined in the Air Force Instruction 11-290, which applies to the entirety of the Air Force. The goals of the CRM program are to maximize effectiveness and combat capability, preserve personnel and material resources, ensure the safety of civilians, and facilitate mishap reduction (United States Air Force, 2020). This program is managed by the Air Force Director of Training and Readiness and is supported by the Air Force Safety Center. The responsibility of managing specific programs is on Commanders and is assisted by local CRM program managers. These individuals integrate CRM skills into flight briefings and debriefings, training syllabi, evaluations, and other approved substitutes. In the Air Combat Command, flying squadrons have a CRM representative that encourages maximum CRM participation in non-required training. This position also will examine grade sheets to determine trends in the squadron’s application of CRM skills which then could be used to address issues.
The core curricula of the program center around communication, crew/flight coordination, mission analysis, risk management/decision making, situational awareness, and finally task management. These were selected to develop aircrew skills in recognizing risks and hazards that can lead to errors and mishaps. The aim is to build proficiency to minimize the conditions that can detract from mission requirements. Despite challenging flying conditions, CRM is a big reason why mishap rates have gone down over the years.
The Air Force breaks down CRM training in multiple phases. CRM is first introduced to students through concepts during initial training such as pilot training. This is followed by CRM training during the student’s time at the formal training unit, which applies CRM skills to their specific platform. Next is the mission-specific continuation training which reinforces CRM skills and knowledge. This is done at a specific reoccurring frequency. In the Air Combat Command, CRM training is required every two years, with additional opportunities for training in between. Next, crewmembers go through instructor CRM training which ensures a high level of proficiency in CRM skills prior to the instruction of students. Lastly, is the facilitator training which allows crew members to be facilitators of CRM training.
The approach that the Air Force has taken meets the criteria for an FAA-approved training course. Let us break it down and understand why. The CRM program was tailored to meet the specified needs of a military organization. The program was oriented to facilitate maximum combat capability while minimizing mishaps using CRM skills. The program is integrated through the entire organization with representatives and inputs from leadership down to the individual crewmember. The program also follows the phases by having a system in place to implement, reinforce, and assess CRM for crewmembers and the organization.
The Future of CRM
The history of CRM has shown us that it has adapted and changed throughout its existence, so what does the future of CRM look like? The overall scope of CRM will remain the same, meaning its use will be focused on making flying safer and more efficient, but the information and means of training will continue to advance.
For example, joint CRM training has been increasingly utilized. This involves the training of different positions outside of the pilots and aircrew in conjunction with the aircrew with the intention of creating a safer and more seamless flying process.
In the end, as technology continues to move forward, so will the understanding of human factors and CRM which may bring with it new methods of training, but the basic building blocks of CRM will remain the same.
These foundational principles haven proven to be an exceptional way to improve safety and efficiency in the work area despite the human factor barriers. Human errors are not limited to just aircrew, the health care industry in the United States has 251,000 deaths due to medical errors annually, which makes it the third leading cause of death in the U.S. (Anderson, 2017).
After seeing the success of lowering mishap rates for the airline industry, the healthcare industry has slowly integrated CRM principles into the way they operate. The utilization of CRM skills in the medical industry is aimed to combat and lower medical errors significantly.
They are not alone; other fields took notice and they too integrated CRM into their workplaces. CRM can now be seen in firefighting and other transportation activities such as the shipping and railroad industries. These industries have tailored their CRM approaches for their respective fields to improve their effectiveness.
Issues With CRM
Though CRM has proven to be very positive for aviation and safety, it does not come without barriers and complications. Often, airlines and other flying entities will hire consultants to design and run their programs, which takes requires a large sum of money, time, and effort. Resources and time are finite commodities, which may hamper the abilities of an organization to successfully implement a CMR program.
Along with resources and time, AC-120-51E highlights error management and culture issues as obstacles to a successful CRM program (FAA, 2004). CRM cannot eliminate pilot error entirely, which means separate skills need to be learned outside the scope of those learned through CRM programs, such as error management. An aircrew member needs to be able to prevent, detect, and recover from errors.
The next issue involves the culture of individuals and the culture of organizations. A successful program requires a safety mindset from individuals and organizations, if the value of CRM is not respected or understood, then the program will not survive. Lastly, accountability may fall through the cracks due to a variety of reasons, which defeats the purpose of having a CMR standard and program to begin with.
Standards must be upheld because safety in the aviation world is the line between life and death.
Something the aviation community should be proud of is its commitment to safety. The reason why there are not many issues regarding CRM is that there is an overwhelmingly big buy-in from aircrew.
A question on a survey regarding CRM training asked if CRM was an important topic to include in training and out of the 10,155 pilots who responded, only 5.5% disagreed (Baker, 2002). This proves the safety mindset that is spread out throughout the aviation industry. This helps bridge the gap between areas where CRM may not be as present such as general aviation communities, which helps eliminate the resources issue. This is also tackled through the existence of the internet.
Anyone can go on the FAA’s website or YouTube to learn the same CRM practices as those taught in the multimillion-dollar programs. These are the main issues and how they are getting combatted to promote a good level of CRM in the industry.
CRM Wrapped Up
Billy Mitchell said, “man can’t fly in rough conditions and expect to watch all those gauges,” upon seeing the DC-3 for the first time (FAA, 2012). This perfectly encapsulates how aviation is constantly advancing. 100 years is all that separates bi-planes looking over World War 1 battlefields and F-22s ripping patterns at Tinker AFB.
These technological developments only do so much to make skies safer. A series of mishaps in the 1970’s highlighted that there were other factors that needed to be considered. To remedy these factors, crew resource management was developed, tested, and improved.
Through its successes, aviation regulatory agencies around the world have made CRM training a requirement for many of those who contribute to flying operations. The results have been positive and even led to the integration of CRM practices to other critical industries.
Humans persist in advancing, developing, and improving technology, even so, in an ever-changing aviation environment, one concept stays the same, safety and efficiency always benefit from the use of proper crew resource management.
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