Evolution of CRM 1

Running Head: Evolution of CRM

Paper # 2 (Accident Analysis #10)

The Evolution of Crew Resource Management

Joshua Minze

Utah Valley University

Jennifer Shamsy, Instructor

SVC 3600X2

Evolution of CRM 2

The crash of United Airlines Flight 173 could have been avoided with a few simple steps.

Flight 173 was a Douglas DC-8-61 that departed out of New York-JFK Airport on December 28,

1978. The flight had a scheduled stop over at Denver International Airport before its final

destination of Portland International Airport (PDX). The DC-8-61 took off out of Denver at

14:47 with 46,700 pounds of fuel on board to complete the last leg of the flight estimated to take

2 hours and 26 minutes. The flight was planned to arrive at Portland International (PDX) at

17:13. All had been going according to plan until the flight crew tried to lower the landing gear.

After hearing a loud noise coming from the right main landing gear, the crew noticed the landing

gear indicator light in the cabin was showing the gear to not be down or locked into place. The

piston rod of the right main landing gear retract cylinder assembly had failed, and the landing

gear indicating system showed the gear up. Captain Malburn McBroom became so engulfed

with assessing the situation that he completely neglected to keep track of the onboard fuel

quantity. Almost an hour was spent flying around in a hold trying to fix the gear issue before a

low fuel state was mentioned to the controllers handling their flight. A few minutes after Flight

173 requested emergency landing priority, the engines began to flame out. At first sight of the

problem the aircraft had enough fuel remaining to assess the landing gear issue and get the plane

on the ground. However, when flying an airplane that burns 220 pounds of fuel per minute,

13,334 pounds of fuel does not allow much time to evaluate other problems. At 18:15, just an

hour and three minutes after entering the hold, all of the aircraft’s engines flamed out. With no

runway or landing strip, Captain McBroom did his very best to set the aircraft down safely. The

crash took place in a wooded and populated area of suburban Portland about 6 miles east

southeast of the airport. There was not a post-crash fire, most likely due to the fuel starvation

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that landed them there in the first place. The wreckage path was about 130 feet wide and

stretched on about 1554 feet long. Two uninhabited homes were destroyed leaving no one

injured that was on the ground. With a total of 189 total occupants onboard the plane, only 10

people lost their lives and 22 people were injured. Miraculously 179 lives were saved this day.

In response to this crash United Airlines re-evaluated their cockpit training procedures

focusing on the then-new concept of Cockpit Resource Management (CRM). Abandoning the

traditional "sky-god-captain" routine of aviation, the revolutionary CRM emphasized teamwork

and communication among the crew and demonstrated an attempt to enhance overall situational

awareness of the crew. "It's really paid off," says United Captain Al Haynes, who in 1989

remarkably managed to crash-land a crippled DC-10 at Sioux City, Iowa, by varying engine

thrust. "Without [CRM training], it's a cinch we wouldn't have made it." (Noland, 2007). CRM

was developed as a response to new insights into the causes of aircraft accidents which followed

from the introduction of flight recorders and cockpit voice recorders into modern jet aircraft.

Cockpit Resource Management, now referred to as Crew Resource Management (CRM), entails

a large range of knowledge, skills, and attitudes including communications, situational

awareness, problem solving, decision making, leadership and teamwork. Throughout the years,

Crew Resource Management has had a positive impact in many different aviation emergencies,

and is now at its 5th generation level.

One of the most vital elements of Crew Resource Management is communication. In

order to produce successful communication, one must understand how the process works. The

very basic form of communication involves two-way communication between a sender and a

message receiver. The sender encodes the information and the receiver decodes the information.

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When effective communication is at work, what the receiver decodes is what the sender sends.

A breakdown in the communication process may occur if the intended message was not encoded

or decoded properly. Comments may be taken the wrong way; a compliment may be taken as an

insult, or a joke might be interpreted as a jab. There may also be barriers in the transfer process

including: noise, vibration, radio clutter, cultural differences distractions, fatigue, stress

incomplete messages, or boring messages that cause day dreaming. Lack of common experience

is a major cause of communication breakdown in a cockpit. When a student’s level of retained

knowledge is not up to par then the words coming from the instructor are often misunderstood or

interpreted incorrectly. A communicator’s words cannot communicate the desired meaning to

another person unless the listener or reader has had some degree of experience with the objects

or topics to which these words refer. The English language can be very confusing; due to the

fact that several words in the language mean different things to different people. This is the

cause of confusion between what is said being received differently from what is really meant to

be interpreted by the receiver. This hurdle to the communication process can be attributed to the

pairing process, and specifically the cultural differences between crewmembers. In this world of

cultural diversity, it is not uncommon to have two pilots with a completely different cultural

background flying together as a crew. Both verbal and non-verbal communications may be

interpreted differently, and this may cause problems during flight, particularly in high-workload

situation.

Power Distance (PD) is the distribution of “power” among individuals and groups in a

society, and how inequalities in power are dealt with in these societies. Societies with a low PD

believe that, inequality should be minimized, all people should be interdependent, and hierarchy

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is an inequality of roles. In practical terms, PD reflects that there is an unequal power

relationship in the cockpit, and a subordinate should not question the decisions or actions of their

superiors. The results of a cross-cultural study conducted in 2001, showed that in cultures with a

high PD safety might suffer from the fact that insubordinates may not have the ability to speak

up when they should, or are unwilling to make inputs regarding leaders’ actions or decisions

(Baron, 1997). It was found that countries such as Morocco, the Philippines, Taiwan, and Brazil

had the highest PD scores, or a culture based on the acceptance of unequally distributed power.

Countries such as Ireland, Denmark, Norway, and the United States scored at the extreme low

end of the PD scale.

An excellent example of a team working together to effectively communicate during a

crisis is the crash of Flight 232 at Sioux City, Iowa. At exactly 1516 hours and 10 seconds on 19

July 1989 a McDonnell Douglas DC-10 was flying out of Denver, when suddenly they

experienced an extremely unusual engine failure. The number 1 and 3 engines were functioning

properly, but the number 2 engine (mounted on the tail) had blown. The stage 1 engine fan split,

causing the rotor assembly to explode, sending metal fragments through 70 different holes in the

tail. These fragments managed to pierce all three hydraulic lines that ran the flight control

system, causing complete loss of all flight controls. Flight 232, originally destined for Chicago,

crash-landed at Sioux Gateway Airport in Iowa. Of the 285 passengers and 11 crewmembers on

board, one flight attendant and 110 passengers were killed. (National Transportation Safety

Board [NTSB], 1989).

Communication between the crewmembers of flight 232 became one of the key factors in

keeping the airplane stable. All flight controls were destroyed, yet the crew managed to work

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together to keep the airplane stabilized. The cooperation of the crew was amazing. They all

maintained their cool and stayed focused on the task at hand. Interpersonal communication skills

were unquestionably displayed in the cockpit. The first Officer openly communicated with the

captain telling him that he had no control of the aircraft, and that he would like to hand over

controls. In doing this, he hoped that the captain could do a better job of stabilizing the aircraft.

(National Transportation Safety Board [NTSB], 1989). Interpersonal communication was also

prevalent when Denny Fisch, a passenger of flight 232, notified the flight crew that he was an

instructor for the DC-10. Considering the aura that surrounds flight instructors, the captain

immediately asked Fisch to come up to the cockpit. As Fisch entered the cockpit he surprisingly

saw both pilots struggling tremendously to keep the shiny side up. Fisch looked at the instrument

panel and saw he didn’t have much advice to give. Survival mode took effect for Fisch, and he

instantly started through his emergency checklists. As fast as he could call out suggestions, the

captain was telling him they already tried them multiple times. After exhausting all of his

options, Fisch anxiously asked the captain what he wanted him to do. The captain told Fisch to

take control of the throttles. (AirDisaster 1997).

Together, all three pilots were not only trying to fly the damaged plane, but were also

frantically talking and brainstorming to come up with helpful ideas. The flight crew (including

flight attendants), ATC, and local emergency workers did an amazing job collectively to save the

lives of the 186 people who survived the devastating crash of flight 232. A pilot’s number one

responsibility in an emergency is to fly the aircraft, and second is to communicate with ATC to

establish that an emergency is at hand. (AirDisaster 1997). The flight crew of flight 232 did just

that. Captain Al Haynes immediately contacted the Minneapolis Center notifying them of an

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engine failure. Minneapolis Center then contacted Sioux City Approach Control and told them

they had an emergency headed their way. In light of a serious problem, like the one on flight

232, advice needs to be given in a calm and steady manor. For Captain Al and all the souls

aboard, the Sioux City Approach Controller, Kevin Bauchman, was ideal. Bauchman’s voice

remained calm and steady throughout the entire time they needed his services. Thinking ahead,

Kevin managed to get every Emergency Response team possible lined up and waiting on runway

22. Runway 31 was the original intended landing runway, but when flight 232 turned onto final

and called out airport insight they were lined up to land on runway 22. So with two minutes

notice Kevin had to get fire trucks, ambulances, and many other service vehicles to move off of

the new landing site. Kevin’s calm voice and organizational skills are a fine example of

extensive training techniques, and good Crew Resource Management (CRM).

Cooperation of the crew has been noted several times, however, we cannot forget the

skills of senior flight attendant on deck, Janice T. Brown. Janice was very experienced and calm

as she displayed her CRM skills when she came to the cockpit. She opened the door and simply

returned to the passengers to get them prepared for whatever might come next. (AirDisaster.com

1997). One could have easily looked into an unstable cockpit at 37,000 feet and shied away

from any responsibilities. This was not the case for Janice; she talked to all fellow flight

attendants and told them to stay calm, careful not to alarm the passengers. Within a few moments

she had the cabin calm, cool, collected, and ready for the unthinkable.

The crash of flight 232 could have been prevented with a thorough maintenance check

and a better-designed airplane; however, the crewmembers displayed the utmost level of training

and courage during the disaster. The National Transportation Safety Board (NTSB) declared,

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“under the circumstances, the UAL flight crew performance was highly commendable and

greatly exceeded reasonable expectations.” (NTSB, 1989). The United Airlines started a course

called Command Leadership Resource Management (CLRM) training in 1980, now called Crew

Resource Management. CRM training plays an important role in reducing accidents throughout

the aviation industry. New enhancements that are added to the program are consistently shared

between all aviation companies. Most of the airlines today include at least two days of CRM or

Human Factors Training for flight attendants during initial pilot or upgrade training. (Utah

Valley University, 2002).

Commercial aviation statistics exhibit the facts that human factors are related in up to 90

percent of all commercial airline accidents. In order to control the amount of human error, the

origination of the error must be fully understood. The error typically comes from many different

origins, and the cost of errors can be exceedingly different. While some errors are due to

negligence, carelessness, or poor decision-making traits, others may be integrated by poorly

constructed equipment, or may result from a normal reaction to a particular situation.

Information is perceived by the brain after the senses pick up the message. The message is then

interpreted through expectation, experience, attitude, motivation, and arousal. Once the brain

has made conclusions about the meaning of a message, the decision-making process begins.

There are several different factors that can lead to bad decisions being made. Training or past

experiences, emotional or commercial considerations, physical or psychological disorders,

motivation, medication, and fatigue are a few obstacles that may stand in the way of a good

decision. When the decision is made it becomes time to take action. Then, directly following

action is the feedback mechanism. Deficiencies in this mechanism might also generate errors.

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To control these errors one must minimize their occurrence by ensuring very high levels of

competence, and designing controls that match up with human characteristics. Training

programs have been developed and designed to increase the co-operation and communication

between crew members in order to reduce the number of errors that are made. One approach to

cost effective training that is often used is the Systems Approach. The first step in this approach

is to determine the training needs through job task analyses. The next step is to provide a clear

job description and analysis. The course content is then determined, and implemented. There

are several different methods for this including; lectures, lessons, discussions, tutorials,

programmed instruction, audio-visuals, and computer based training. Another avenue used to

control human error is to reduce the amount of error remaining by cross-monitoring and crew co-

operation.

The evolution of Crew Resource Management (CRM) Training in commercial aviation

can be summed up with two little words, “error management.” The roots of CRM training in the

United States are usually traced back to a workshop, Resource Management on the flight deck,

sponsored by the National Aeronautics and Space Administration (NASA) in 1979. (Department

of Psychology, 1999). This conference was the outcome of NASA research into the causes of air

transport accidents. The research presented at this meeting identified the human error aspects of

the preponderance of air crashes as failures of interpersonal communications, decision making,

and leadership. This was all applied to the process of training crews to reduce the level of pilot

error within the cockpit. The effort was to attempt to make better use of the human resources on

the flight deck. When talking about the evolution of CRM, the process of growth and

development must constantly be acknowledged.

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The first generation of cockpit recourse management was initiated in 1981 by United

Airlines. A Managerial Grid was created and used to enhance their managerial effectiveness.

Programs and courses were created that emphasized changing individual styles and correcting

deficiencies in individual behavior such as a lack of assertiveness by juniors and authoritarian

behavior by captains. This curriculum was psychological in nature, with a heavy focus on

psychological testing and general concepts such as leadership. In addition to the classroom

training some programs also used simulators for Line Oriented Flight Training (LOFT). During

LOFT training both serious and non-serious situations present themselves to pilots during flight.

Each situation provides a valuable learning experience for the pilot.

The second generation of CRM is actually when they dropped ‘cockpit’ and added

‘crew’ to the title. The new type of training included intensive seminars with concepts such as:

team building, briefing strategies, situation awareness and stress management. Some modules

addressed different decision making strategies, while others focused on breaking the chain of

errors that can result in catastrophe. Although the second generation of training was accepted far

greater than the first generation, the skeptics were still talking of “psycho-babble” and

“synergy.”

The Third Generation of CRM began in the early 90’s, where it began to divide and

proceed down multiple paths. Training began to reflect the personality of the aviation system,

where the crew was being taught to function as a team. Input factors such as organizational

culture that determine safety were being included in the training process. CRM, in the third

stage, began to extend to other groups within airlines such as flight attendants, dispatchers, and

maintenance personnel. This was also the beginning of the joint cockpit-cabin CRM training

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that was facilitated by several different airlines. The leadership role of new captains was put to

the top of the list in this phase of training.

With the fourth generation came a major change in the training and qualification of flight

crews. 1993 brought the initiation of the Advanced Qualification Program (AQP). AQP was

started as a voluntary program that allowed air carriers to develop innovative training that fit the

needs of their specific organization (Department of Psychology, 1999). With the new lenient

rule came a new standard as well, the requirement of LOFT and CRM training for all flight

crews, and to integrate the CRM concepts into technical training. The primary goal of the fourth

generation was to ensure that decisions and actions were informed by consideration of “bottom

lines,” and that the basics of CRM were observed in non-standard situations.

The fifth, and final, generation of CRM training was indeed a search for a universal

foundation, which earned it the title of Error Management. The concept being taught here is

more sharply defined, and is accompanied by a proactive organizational support. Basically we

will always have error; it is just a matter of how to deal with the error when it is starring you in

the face. The core of the fifth phase is the principle that human error is both inevitable and a

valuable source of information as well. Since error is inevitable, CRM can be seen as a set of

error antidotes with three lines of defense. First, avoid the error. Then, trap initial errors

altogether before they even take place. Finally, lessen the consequences of those errors that make

it through the first two steps. The same set of countermeasures is used in each situation; the only

difference between the three occurs when the problem is detected and addressed. In addition to

controlling error, organizations need to take steps to recognize the source of errors in their

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operations. The data that is generated by this Error Management system is compiled together

and used to prevent or minimize the recurrence of incidents.

More important than the skills and knowledge that are essential to fly an aircraft is the

cognitive and interpersonal skills required to manage a flight within an organized aviation

system. The cognitive skills that are needed rely on the mental processes that are used for

maintaining situational awareness, communicating effectively, for activities associated with team

work. Crew Resource Management (CRM ) should be practiced in the single man cockpit as

well as the multi-crew airline cockpits. CRM started many years ago with the same goal in mind

as today: to eliminate the majority of error that might take place during flight on an aircraft. No

one can truly calculate the exact number of lives that CRM has saved since its birth in 1979, but

now more than ever CRM has become accepted among the aviation community. Since its birth,

Crew Resource Management has developed into an essential management concept that embraces

the principles and skills that enable flight crews to communicate effectively, make smart

decisions, and operate at optimal efficiency, all while capitalizing on the safety of the flight.

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References

AirDisaster.com. (1997). Investigation: United Airlines flight 173. Retrieved March 10,

2010, from http://www.airdisaster.com/investigations/ua173.shtml

Baron, R. (1997). Barriers for effective communication: implications for the cockpit. Retrieved

March 14, 2010, from http://www.airlinesafety.com /editorials/ BarriersTo

Communication.htm

Bogash , R. (2008). Gliding into PDX in a stretch 8. Retrieved March 11, 2010, from

http://www.rbogash.com/Stories/UAL_PDX.html

Department of Psychology. (1999). Aerospace crew research project. Retrieved March 16,

2010, from http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB/

publications/pubfiles/Pub235.pdf

Haynes, A. (1997). Eyewitness report: flight 232. Retrieved March 12, 2010, from

http://www.airdisaster.com/eyewitness/ua232.shtml

Helmreich, R., Kanki, B., & Weiner, E. (Eds.). (1993). Cockpit resource management.

California: Academic Press.

National Transportation Safety Board. (1989). NTSB accident report. Retrieved March 11,

2010, from http://www.airdisaster.com/reports/ntsb/AAR90-06.pdf

Noland, D. (2007). Cockpit teamwork. Retrieved March 10, 2010, from

http://www.military.com/NewsContent/0,13319,152543,00.html

Utah Valley University. (2010). Lectures 1-12, Retrieved March 10, 2010 from

http://uvsc.aviationuniversity.com/avsc3600x2/index.htm