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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
Evolution of CRM 3 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.
Evolution of CRM 4 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
Evolution of CRM 5 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
Evolution of CRM 6 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
Evolution of CRM 7 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,
Evolution of CRM 8 “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.
Evolution of CRM 9 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 cooperation. 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.
Evolution of CRM 10 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
Evolution of CRM 11 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
Evolution of CRM 12 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.
Evolution of CRM 13 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
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