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Crew resource management or cockpit resource management (CRM) is a procedure and training system in systems where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit.
The training originated from a NASA workshop in 1979, which found that the primary cause of most aviation accidents was human error.
CRM has since been adopted in different industries and organizations including fire services (to improve situational awareness on the fireground) and the marine industry, where CRM is referred to as BRM (Bridge Resource Management) or MRM (Maritime Resource Management).
Human performance problems cause 60-80% of all accidents and incidents. Improving human performance / CRM skills is the best way to bring the accident / incident rate down.
CRM is aimed at improving: Crew effectiveness in the aircraft Interpersonal Communications Situational Awareness Identification and Management of Error Teamwork Performance due to Fatigue
Accident Case Study Pam Am / KLM Tenerife, Canary Islands, 27th March 1977
The Tenerife airport disaster occurred on Sunday, March 27, 1977, when two Boeing 747 passenger aircraft collided on the runway of Los Rodeos Airport (Tenerife North Airport) on the Canary Islands. With a total of 583 fatalities, the crash is the deadliest accident in aviation history. The KLM flight attempted to take off while the Pan Am flight was still on the runway. The resulting collision destroyed both aircraft, killing all 248 aboard the KLM flight and 335 of 396 aboard the Pan Am flight.
Captain Van Zanten had access to some of the following sources of critical information that conditions were not yet safe to take off:
1. The island was in cloud most days. 2. Not conversant with the airport. 3. The airport was very busy with diverted planes 4. 400 people had been up all night 5. He had limited information 6. He wanted to get flying so he didn’t exceed his flying hours 7. The airport was shrouded in fog. 8. The captain did not ask permission to take off. 9. The 1st Officer had indicated that they did not have clearance
to take off. 10.Anxiety to get off the ground. 11.The captains personality. 12.The 1st Officer would not contradict the captain.
Why did he disregard them: 1.Sole decision making 2.Inadequate use of available
resources. 3.Not sticking to SOP’s
The Swiss Cheese Model
By having processes, systems, checks in place it will help reduce the chances of the holes lining up, its when they line up that accidents will occur.
Checks & Processes
Errors
•SOP’s
•Training
•Maintenance
•Equipment
•Financial Constraints
1. Failure to meet targets 2. Use of undocumented Procedures 3. Departing from SOP’s 4. Violating minimums or Limitations 5. No one Flying the Aircraft 6. No one Looking Out the Window 7. Communications 8. Ambiguity 9. Unresolved Discrepancies 10. Preoccupation or Distractions 11. Confusion or Empty Feeling
CRM is the timely sharing of information between the crew to obtain the optimal outcome in the safest possible manner. CRM applies to anyone who is on the aircraft. CRM involves a 3 way dialogue between the
pilot, winchman and winch operator. CRM involves Pre-planning, plans A,B,C, the
ability to change, alter, amend or even abort the mission. CRM involves controlling what happens in
and around the aircraft, this includes ground crew e.g. Fire, Ambo, Police
The Art of Good Communication
Situational Awareness
Past
Present
Future SA
Situational awareness allows you to understand what is happening around you so that you can quickly respond to an unexpected and time critical event.
A key component of CRM for winching
Situational awareness is a term used to describe a persons awareness of their surroundings, the meaning of these surroundings, a prediction of what these surroundings will mean in the future, and then using this information to act.
Collective Situational Awareness
Pilots Situational Awareness
Crewman's Situational Awareness
Collective Situational Awareness
Factors That Reduce Situational Awareness
Insufficient Communication Fatigue / Stress Task Overload Task Underload Operating Conditions Group Mindset: BWADITW (But We’ve always Done
It That Way) Personal Issues Channelized Attention (Tunnel Vision) Complacency Personal Conflicts
Taking into Consideration
Winching with SAR and Ambo Training Pre flight planning Talk about the mission Discuss options Do you have to winch, is there a safer option (Should winching be the last option ???) Explain procedures (regular training) Ask questions if not sure, never assume There's no such thing as a stupid question Challenging for continuous improvement Vs BWADITW Pilots aren't God but they are in charge of the Helo and have the final say in relation to safety of the Helo and crew. If you're not happy about something speak up. It’s your life.
What can we do to make the job safer !!
