--------j! OP RATIO / CREW RESOURCE MANAGEMENT

::;;8s;;;:;i~~a:~o::;;

~ 1979,~ I' THE wake of8 certain findings and.: recommendations~ by the National Aero-~ nautics and Space~ Administration (NASA), the concept of Crew* Resource Management (CRM) is widely used today by airlines~ the world over to enhance air safety through improved per-i formance of and coordination amongst members of the flight~ crew. NASA research had suggested that human error played!:! a critical role in air crashes and the contributory factors were~ inadequacy of interpersonal communication as well as leader-~ ship and decision-making in the cockpit.s: Data milked from Cockpit Voice Recorders retrieved after

For tSafetyIThe concept of Crew Resource Management is to train aviation

professionals to prioritise and take action in high -stress,high -rtsk environment I

By Mahesh Acharya,Bangalore

accidents indicated that more oftenthan not, the cause of the disaster lay.not in technical failure or poor pilotingskills per se, but in the lack of correct.coordinated and professional responseby the crew to an extraordinary situa-

tion or unforeseen development. It was observed that lack ofproper communication amongst the crew generally had delete-rious effect on teamwork leading to degradation in the qualityof decisions by the commander-a sure recipe for disaster.

EVOLUTIO OF CRMBased on this concept. in 1981. United Airlines initiated a train-ing programme for its pilots then described as Cockpit Re-source Management. Since then. CRM techniques have evolved

28. Sp·S aielrl. ISSUE 1 • 2010 ~ www.sPSAIRBUZ.NET

/ CREW RESOURCE MANAGEMENT 1------~op RAT 0

considerably the world over to find wider application extend-ing to personnel beyond the cockpit to those engaged in the op-eration of the aircraft, with common rationale for air safety. Thechanges came about after the realisation that in the conduct offlight operations. safety of the aircraft depended on pilots, airtraffic controllers. flight dispatchers, cabin crew, maintenancepersonnel, push-back crew, ramp and aerobridge operators andmarshallers. In the early 1990s. as CRM training was progres-sively extended to these groups. the nomenclature was modi-fied to Crew Resource Management.

In India, CRM training is an essentialpart of annual refresher training for pilotsand has been found to be useful. There isno absolutely standardised pattern of CRMtraining and airlines usually customise theprogramme to suit their specific or uniquerequirements. However. CRM is yet to finda niche in the operating philosophy of fly-ing establishments other than those ofairlines such as flying training institutions,business aviation, non-scheduled and pri-vate operators. The concept of CRM is notrestricted to only multi-crew environment;it is equally applicable to single pilot opera-tions that are required to mesh with otherair traffic as also with the different groundsupport agencies while on a mission.

Analysis of investigation reports relat-ing to accidents and incidents suggeststhat extending the concept of CRM tonon-airline flying environment can helpprevent or reduce the possibility of mis-hap. While accidents may occur in differ-ent environments and circumstances, theunderlying cause factors that lead to acci-dents often are strikingly similar to thoseoccurring in scheduled airlines.

ciplines involved in the operation of aircraft.

MULTI-CREW ENVlRO ME TA study of airline accidents in the last few decades reveals thatthe majority of accidents take place during take off and landing.In October 2009, a senior pilot of an airline was travelling as anAdditional Crew Member (ACM) and was seated in the jumpseat located behind the pilots' seats. An ACM has the statusof a passenger and he or she is not expected to interfere withthe operation of the aircraft. However. while on approach for

landing at Mumbai airport, without priorwarning. the ACM pulled out a circuitbreaker to test the reaction and skillsof the commander of that flight. His ac-tion led to sudden failure of critical sys-tems such as the Auto Pilot. EnhancedGround Proximity Warning System andthe Flight Director System, destabilisingthe approach profile. The episode re-vealed total lack of discipline as the se-nior pilot in question was not expectedto be in the cockpit in the first place orplay pranks and that too, in the criticalphase of flight. The commander of theflight is equally responsible for the inci-dent as he failed to exercise his author-ity and allowed unauthorised access tothe cockpit. Fortunately, the commanderwas able to cope with the situation andlanded the aircraft safely. Lives of thoseon board were needlessly put to greatrisk as the thoughtless and irresponsibleact by a professional pilot led to a poten-tially disastrous situation. The episodereflects complete disregard for CRM.

The Tenerife Disaster of 1977, inwhich two Boeing 747s, one of KLM andthe other of Pan Am, collided on take off.There were 583 fatalities making it theworst disaster in the history of civil avia-tion. The cause of the disaster was pri-marily faulty communication amongst

the cockpit crew that led to the commander executing take-offwithout clearance from the ATC. The underlying cause behindthe flawed communication was the huge difference in the ex-perience and seniority level between the commander and therest of the cockpit crew. The demean our of the Captain wasdomineering and the First Officer as well as the flight engineerfailed to forcefully tell the captain that he was making a seriousmistake even as they were fully aware that the KLM aircraft wasnot cleared for take off. The relative status of the captain andcrew is termed as Trans-Cockpit Authority Gradient (TCAG). Asteep TCAG militates seriously against CRM as was the case inthis episode and hence is not conducive to air safety.

-7 Theconcept ofCRMisnotrestrictedto onlymulti-crewenvironment;iti equallyapplicable tosingle pilotoperationthat arerequired tomesh withother airtraffic

THE CO CEPT DEFINEDThe concept of CRM is to train aviationprofessionals to prioritise and take ac-tion in high-stress, high-risk environmentbased on span of responsibility, situational awareness, commu-nication skills, problem solving, decision making, self disciplineand teamwork. However, as the possibility of human error cannever be totally eliminated, the thrust of CRM training is to de-velop countermeasures to manage human error.

This is achieved through improved synergy amongst thedifferent agencies involved, bridging communication gaps,eliminating the possibility of errors, containing the effect of in-advertent errors as soon as they occur and controlling the ad-verse outcome of errors whose effects could not be contained.The objective is put a management system in place to opti-mise employment of human and material resources as also toharmonise procedures to enhance efficiency of flight opera-tions with a positive impact on air safety. In the final analysis,the central theme of CRM is to raise assurance levels of get-ting high quality decisions in the management and conduct offlight operations.

Described in the succeeding paragraphs are episodes thathighlight the need for CRM amongst personnel of different dis-

FLYING TRAINING OPERATIONSCRM in a flying training environment, especially in flying train-ing schools, would need a different approach from the one ad-opted for airlines. Although some flying schools have conductedseminars in CRM, practical application is yet to find wide ac-ceptance. Most of the young trainee pilots aspiring for a career

ISSUE1 • 2010' SP'S aiBUZ· 29

----IOPERATIO S / REW RESOURCE MANAGEMENT 1--1 --

in the airlines are eager to impress their peers by engaging inactivities that risk their lives and that of others on the ground.For example in 2008. a trainee pilot. while flying a trainer air-craft. violated a Standard Operating Procedure (SOP) and usedautopilot without functional knowledge. As per the accidentreport. he was flying solo and ventured over a lake withoutauthorisation. Since he was flying at a very low altitude, thewheels of the aircraft grazed the surface of the water. Eventual-ly he crash landed but was lucky to escape unhurt. The aircraftwas damaged beyond repair. The importance of self-discipline

gramme the FMS of all operational aircraft with the routes andholding point data. In October 2009, the PBN system was intro-duced in Chennai and when Chennai-Bangalore flight operatedby a domestic carrier took off, the ATC was under the impres-sion that the aircraft would fly using the PBN system. How-ever, the FMS on that particular aircraft was not programmedappropriately. Hence the controllers had to resort to the con-ventional method. This episode highlights the importance ofcommunication and situational awareness between AAl andairlines as well as between pilots and ATC.

in aviation cannot be underestimated. Through the concept ofCRM. the trainee pilot can be made aware of how omissionscan affect performance in a multi-crew environment.

AIR TRAFFIC CONTROLLERSIn 2008, a Performance Based Navigation (PBN) procedurefor Air Traffic Control (ATC) was introduced by the AirportsAuthority of India (AAI) at Mumbai, Delhi and Ahmedabadairports. The aim was to reduce workload for both pilots andcontrollers. To use this system, the Flight Management System(FMS) on board the aircraft should have data for airport of de-parture. en route navigation and arrival airports preloaded.

In the initial stages. AAl trained over 100 staff members onthe PBN system. AAI had also requested the airlines to pro-

Communication and error avoidance was exemplified bythe ATC in Chennai when the ground-based PNB system failedin November 2009. Controllers could not monitor aircraft be-yond 60 miles. Information regarding the situation was dissem-inated to other airports that delayed departures of subsequentflights thus obviating convergence and congestion of traffic inChennai controlled airspace. This synchronisation helped easethe load on the controllers until normalcy was restored.

FLIGHT DISPATCHERSCRM training for Flight Dispatchers (FD) is as important as itis for pilots. The syllabus for CRM training for FDs as of now isfocused on human performance which includes aviation psy-chology and interpersonal verbal and non-verbal cornmunica-

30· SP'S aiBUZ • ISSUE 1 • 2010 ~ www.sPSAJRBUZ.NET

I OPERATIO S / CREW RESOURCE MANAGEMENT ~

tion skills, An FD when on duty is expected to have awarenessof a wide range of disciplines and activities. He must know theflight plan. details of cockpit and cabin crew. requirement offuel onboard, alternative plan and other details relevant to op-erations and safety of flights. He needs to interact with pilots.other Ffrs.Ioad planners. aircraft maintenance engineers. man-agers and meteorological personnel. CRM training in his casewill help organise and prioritise information relevant to his re-gime of responsibilities and improve his capability to respondto unfamiliar or emergency situations.

It is well known that any major operational decision by themanagement of airlines affects all the employees either directlyor indirectly both at the occupational and personal level. Thismay have a direct impact on their performance as it did in thefollowing case. In June 2009. an Indian operator centralisedits flight dispatch operations for its international sector on anexperimental basis. Workload for experienced dispatchers in-creased as they had to also take care of flights of other opera-tional bases. Inexperienced dispatchers assigned dispatch du-ties were overloaded with inherent implications for air safety.CentraIised flight dispatch affected pilots adversely as some ofthe dispatch related workload got transferred on to them.

CRM stresses on the need for free and fair communicationpractices and this concept was applied in an extraordinary emer-gency situation by a flight dispatcher with United Airlines (UA).He was in charge of the UAFlight 175 that crashed into the WorldTrade Center (WTC) and Flight 93 which went down in an openfield in Pennsylvania on September 11.2001. He was also in chargeof 16 other flights that were either taking off or ready to take offthat day. When he reaIised that the hijacked planes were deliber-ately crashed into the WTC and the Pentagon. he contacted all hisflights to "beware of intrusion". He sent over 100 text messages toall the aircraft through the Aircraft Communications Addressingand Reporting System. a digital data-link system for transmissionof simple text messages between aircraft and ground stations. Hisactions saved the lives of passengers and crew of UA flight 23 astake off was aborted and six passengers who would not initiallyget off the plane. disappeared into the crowd when they alighted.The authorities later found copies of incriminating documents inthe luggage left behind by these passengers.

FLIGHT ATTENDANTSIn 1989.Air Ontario Flight 1363 crashed because the wings of theaircraft could not generate enough lift to clear trees beyond theend of the runway due to accumulation of ice on the wings. Bothpilots were killed along with some passengers. Several of the sur-vivingpassengers informed the Flight Attendants (FA) about theice accretion on the wings. Unfortunately. the FAs did not com-municate to the flight crew this observation by the passengers.

Emergency evacuation procedures differ with aircraft typeowing to differing positions of emergency exits. FAs are retrainedon this aspect as they transition from one aircraft type to an-other. In emergency situations. action expected by FAs can beprioritised. This did not happen in September 2009. where FAsevacuated passengers in an emergency. While a Boeing 747-400was lined up for takeoff at Mumbai airport. engine number onecaught fire due to fuel leak. As per reports. FAs deployed escapechutes only on the left side where the fire occurred. They failedto open the exits on the right side. As only half the number of ex-its was activated. it was difficult for the FAs to ensure quick andsafe exit of passengers in panic. With proper CRM training. the

FAs might have acted with better professionalism and efficiency.CRM training for cabin crew ought to be mandatory as their roleis critical to air safety.

GROU D PERSONNELOn the ground. accidents and incidents due to omissions arenot uncommon in a highly dynamic environment where groundduty aviation personnel such as maintenance engineers. loadplanners. aero-bridge operators. push-back tractor operatorsall work towards preparing a flight for departure. Following in-cidents will indicate dereliction of duty that could have beenavoided through proper CRM training. In December 2008. atthe IGI Airport. a passenger fell to the ground while crossingover from the aircraft onto the aerobridge, and was seriouslyinjured. There could have been a lapse on the part of the differ-ent agencies involved such as FAs. the aerobridge operator orother ground personnel on site.

In another incident in 2004. the ground crew did not in-form the pilot that they were experiencing problem in discon-necting the tow-bar of the push-back tractor. With the groundcrew out of sight. the commander assumed that the crewhad left. He released the parking brakes and moved forwardresulting in damage to the nose wheel. In this incident. theSOP related to communication between pilot and ground crewwas disregarded. In another example. in 2008. at the Kolkataairport. lack of situational awareness led to serious injury tothe refueling crew. A loaded luggage tractor collided with thepush-back tractor that hit the crew who were refueling the air-craft. Recently. at the IGl Airport. the cargo door of a specialaircraft that was to carry a VVIP was damaged when it was hitby a catering support vehicle.

CRM aims at enhanced situational awareness. Incidents ofthe type described above are proof enough that ground crewought to be imparted CRM training to enhance air safety.

PHILOSOPHY & PROFESSIO ALISMCRM as a concept has been practiced by the airline industry forthree decades and has now become an integral part of its train-ing programmes. Over the years there has been strengtheningconviction that CRM which aims to combine a realistic manage-ment philosophy with professionalism. contributes positively toenhancement of air safety. CRM aims to nurture an operating en-vironment wherein free and forthright communication especiallyupwards is encouraged. This is particularly important when theTrans Cockpit Authority Gradient is steep.

The essence of CRM is enhanced situational awarenesssupported by effective communication. Situational awarenessinvolves conscious recognition of all the factors and condi-tions-operational. technical and human-which affect thesafe operations of an aircraft. It is incumbent on the part of thecrew to bring to the notice of the commander any dichotomybetween the desired situation and the actual situation as thisis often the first symptom of en emergent problem. Delay inappreciation of the situation and dissemination of precise in-formation to the right quarters could spell trouble.

It needs to be understood that CRM is no panacea for allthe ills that threaten air safety. While CRM has limitations. therationale for training continues to be relevant and gain impor-tance as the concept evolves with galloping aviation technolo-gy and more is known about the dynamics of human behaviour.especially in a group. m

ISSUE 1 • 2010 • sp·S aiBUZ • 31