How Crew Resource Management Makes Flying Safer
On December 29, 1972, an Eastern Airlines Lockheed L-1011 with 176 people aboard crashed in Florida’s Everglades only 3 minutes from touching down at Miami International Airport. Three flight crew members, the Captain, First Officer and Flight Engineer became focused on a landing gear indicator light bulb that was not illuminated. As the airplane descended rapidly the three pilots continued to fuss with the indicator lamp. This marked the beginning of a series of horrible aviation accidents in the 1970s involving highly trained, professional flight crews.
The Beginning of Crew Resource Management
Something had to be done and that same year a British aviation psychiatrist and professor, Elwyn Edwards, developed the beginnings of, what originally was called, “Cockpit Resource Management” that since has been expanded. CRM now includes crew members including flight attendants, on or off duty aboard an aircraft as well as others on the ground and today is known as Crew Resource Management. Little by little, Dr. Edwards’ concepts have been built-upon and enhanced culminating in a comprehensive study and proposal by NASA in 1979. The International Civil Aviation Organization (ICAO) has been instrumental in mandating CRM training and vigilance in aviation and has encouraged worldwide government aviation agencies like the FAA to comply with their CRM standards and protocols.
The NASA studies resulted in the belief that the primary cause of aircraft accidents was human errors created from interpersonal communication, leadership and decision-making problems. As defined, Crew Resource Management is a methodology in which the resources of equipment, procedures and people are collectively utilized as needed to safely complete every flying task. The individual components of CRM resources are communications, situational awareness, problem solving, decision making, and teamwork.
How Crew Resource Management Works
You are driving on a busy expressway. The sun is in your eyes. As you attempt to put them on you drop your sunglasses and they slide to the passenger side floor of the car. You should:
- A. Forget about retrieving your sunglasses and continue driving even though the sun occasionally blinds your vision so your passenger doesn’t think you’re a wimp.
- B. Pull over on the shoulder to safely retrieve the sunglasses before pulling back onto the busy highway.
- C. To demonstrate your prowess as a driver, you reach down to the passengers’ side and grab your
- D. You ask your passenger to hand you your sunglasses.
Obviously, answer “D” is best because it allows you to remain focused on control of the vehicle while using someone who is not otherwise busy to complete the task. This example is the essence of what Crew Resource Management is all about.
CRM is not about technical knowledge and the skill of flying an aircraft. It is he interpersonal and cognitive processes of situational awareness, communication, problem solving, decision making and working as a team.
Situational awareness is knowing what is going on around you and recognizing your place in the “big picture.” Walk through any Walmart and you’ll see any number of examples of people who lack situational awareness. As you walk down one aisle suddenly some guy who had stooped down to look at canned prunes stands up and immediately backs into you without looking up first. He had no idea that there could possibly have been anyone behind him even though your grocery cart wheels can be heard for miles around as you approached him. We don’t know where his head was but maybe that’s why he’s buying the prunes.
Don’t get me started on those myopic customers walking around glued to their iPhones, although they are great fun to watch when they walk into a clothing rack or knock over a display of ketchup bottles.
Crew Resource Management applies all the resourceful assistance each crew member requires to safely and efficiently perform flight operations. It includes all direct and peripheral personnel. Besides the immediate flight crew, it can include other pilots who are riding as passengers, jump- seaters, flight attendants, mechanics that may be on board; via radio, utilizing air traffic controllers, company dispatchers and pilots of other aircraft. For instance, you hear an aircraft ahead of you report that it flew through a large flock of birds. Use this information for your own benefit. “Old thinking” was that a pilot must be a “super pilot” and be able to do it all without asking for help. Not so. But pilots who are act autonomously and are unwilling to accept outside help tend to make big mistakes.
Crew Resource Management starts with receiving information, analyzing then making it meaningful. From this, analysis of all the choices enables the best decision out of possible alternatives. The consideration of various alternatives should include any available information, knowledge, prior experience, expectation, context, goals and greatest possibility of a successful outcome. There are times when decisions have to be made quickly, such as when an evasive maneuver is necessary to avoid a mid-air collision. In these instances you must fall back on training and procedures. In the example just cited…traffic at 12 o’clock and closing in on you fast, you veer to the right as per the Aeronautical Information Manual. But what if the bonehead closing on you veers the wrong direction and turns left? You must be willing to amend your response now. This is one of those extreme situations that fortunately does not arise very often. Most situations afford enough time to consult the non-flying pilot. There may be considerations that occur to that pilot that you omitted in your decision and the other pilot’s input will make the final decision a better one. Brittle methods practiced for years and unwillingness to consider others’ suggestions and unwillingness to do nothing have been diminished thanks to CRM, which is a giant leap forward in enhanced safety.
What Would You Do?
You’re headed straight for a black cloud. To its left is a blacker one. To your right the clouds are even blacker than the one on your left. Ah! No sweat…do a one-eighty, right? But the front is moving rapidly and has closed off everything behind you. Probably doing nothing and staying on course is one of the choices. Of course, there’s other things that can be tried like changing altitudes (the middle third of a cumulonimbus is usually where the most violent weather is found), slow up so you don’t hit the “potholes” so hard once you’re in the cloud. Ask your non-flying pilot to check on ride reports ahead of you. Maybe the blackest cloud wasn’t all that bad as reported by an aircraft immediately in front of you. What’s the radar show? Turn on your ADF receiver and watch the needle swing. It points to the area of strongest static caused by lightning discharges. Cinch up your seat belt and tell your passengers to do the same. If you have auto-ignition, turn it on. Follow the procedures in the checklist for turbulence and heavy precipitation penetration. And ask you non-flying pilot what he or she thinks. Maybe the non-flying pilot is more skilled at use of the radar than you and can “see” where the passage ahead would be better. Crew Resource Management uses everything at your disposal.
An important component of CRM is use of standardized checklists for normal, abnormal and emergency operations. When pilots start creating impromptu procedures things can turn ugly real fast. Checklists are developed, tested, re-tested, evaluated and authorized from manufacturers and the FAA have worked out the kinks. Obviously, if one pilot starts extemporaneously throwing switches, the other pilot won’t have a clue as to what his partner is attempting to achieve. Checklists. Checklists. Checklists.
Long overdue, awareness of fatigue and workload have fortunately become important considerations the last few years. There are times when the cockpit gets very busy and at those times both pilots should be sharply attentive. Even though one pilot may be listening to, say, the ATIS frequency and not monitoring the active ARTCC frequency, that pilot should continue to monitor that frequency in case something transpires that require urgency in getting back “into the loop.” Even ATC has changed their policies on issuing clearances, recognizing that pilot workload and information retention has its limits. ATC will not issue a clearance with more than 2 numbers at a time. If they want you to turn left to a heading of 160, descend to 4,000 feet and slow to 230 knots, they’ say, “Ercoupe 38 X-ray, turn left heading 1-6-0, descend to 4,000.” You respond with the read back. Then they call you and say, “Ercoupe 28-X-ray slow to 230 knots.”1
As aviation has developed, automation has increasingly become more integrated into the pilot’s world. Flight management systems (FMS) and a myriad of aircraft-specific enhancements like auto-throttles, thrust management systems and FADEC-controlled engines, to name a few, have placed more importance on staying on top of what’s going on. While the civilian perceives automation on an airplane as something that makes less work for pilots, it’s actually the opposite. In fact, automation requires more vigilance than non-automation, so pilots must now be more in a systems management role than switch-and-control manipulation role. This makes it imperative that Crew Resource Management be applied to inputs, outputs, programming and cross-checking of all automatic systems.
Simply stated, Crew Resource Management is two or more people performing as one. Pilots utilizing CRM help each other by filling in any voids when tasks mount up and one person can’t do the job without sacrificing attention to the airplane. As mentioned earlier, CRM involves people other than the pilots as well. An example is approaching an airport with deteriorating weather. One of the pilots could direct his or her attention to switching radio frequencies to get a weather update, however both pilots may be very busy. The ATC controller has access to the same weather information that pilots can get from the ATIS, so why not just key the microphone and say, “Approach (control)…you got the latest weather for Booger International?”
Personal Experience with Crew Resource Management
Some years ago I was flying with another pilot who consistently demonstrated acute and superb skills. One Monday morning, we took off to start a trip and he seemed uncharacteristically “behind” the airplane. I thought his unusual sloppy and lethargic performance was maybe just that this was a very early morning departure and he “wasn’t awake yet.” Second leg of the trip, he was flying the approach and the profile for an ILS was at glide slope intercept to call for landing gear down and full flaps. Glide slope intercept came and he started to descend which, of course built up speed rapidly. He then started reducing the power to counteract the speed. Something was wrong. I said, “Gary, you ready for the gear and flaps?” Breaking his reverie he responded, “OH! Oh yeah…uh…gear down…uh full flaps…uh… and the before landing checklist.” We completed the approach and landing without further incident. After shutting down the aircraft and putting our other duties behind us I asked him if everything is alright. He said, “Well, no. On Friday my mom passed away and yesterday my dad had a heart attack and died.” Whoa! What was this man doing flying an airplane? We were not in a position where I could initiate a crew change but I did convince him to blow off the rest of the trip when we got back to our domicile and replace him with another crew member. I wish I had known before we had even started that morning so I could have intervened. Knowing the stress he was experiencing, at the very least my CRM observations would have been heightened to watch for mistakes and omissions earlier. The goal of CRM is for two people to act as one well-tuned machine.
My first exposure to CRM was my first job as a whipping-boy/corporate co-pilot in a two-pilot turboprop. The guy I worked for was a jerk. But I sucked-it up because I needed to build flight time if I was going to make a career in aviation. One night he ordered me to get him a cup of coffee. The galley was toward the rear of the passenger cabin so I responded dutifully. Just as I returned with his %&*# cup of coffee we flew into an area of turbulence. I am standing there holding his cup of coffee and he turns to me and barks, “NOT NOW! Do something…GET RID OF IT!” I was not a coffee drinker but the only thing I could think to do as we were getting the you-know-what kicked out of us was to drink the coffee quickly. I wanted to puke. In retrospect perhaps my choice to alleviate the problem created by the captain’s cup filled with coffee in some abstract way was a bit of CRM. I also know that that first cup of coffee I drank lead me to try it again and that now I am a die-hard coffee drinker.
So the moral of the story is Crew Resource Management is beneficial to pilots because it enhances safety and allows us to discover coffee.
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1 – Ercoupe? 230 knots? I’m joking, right?
Advisory Circular for Air Operators, “Training Programme for Crew Resource Management,” International Civil Aviation Organization, 2013.
Internet Website: http://www.crewresourcemanagement.net/information-processing/decision-making
Featured Image: Kent Wien