Professional Documents
Culture Documents
Table of Contents
Module 1
Session Plan
Module no 1
Duration 2 hours
Learning On completion of this module the student will be able to define CRM, understand the
Objectives background to its conception, and the importance of CRM in the organisation and in
flight safety
Student None
prerequisites
Participant Handouts – Company specific syllabus (if one exists), CAA Significant Seven statistics.
materials
Course introduction
Use the following guidelines to provide an appropriate personal welcome to the course.
Slide – Introduction
Trainer introduction
Good morning and welcome to this Crew Resource Management course. The course runs
for 2/3 days (operator’s discretion). It is a very practical course run in an informal and
friendly manner, and you will find you will be participating a great deal throughout.
Trainer to introduce self and allow class to introduce themselves.
Student introduction
Domestic arrangements
if they are not clear about what you are saying or if they miss
something.
Contract between us. Express the need to respect each other and
uphold confidentiality.
This is your course, please participate as much as possible, the more input you give the
course, the more you will get out of it.
Syllabus
Work through the syllabus
The origin of Crew (or Cockpit) Resource Management (CRM) training is most often traced
to a NASA workshop in 1979 that focused on improving air safety by reducing human
error. The workshop was convened to consider NASA research which indicated that the
majority of aviation accidents were caused by failures of interpersonal communication,
leadership, and decision making in the cockpit.
Training which derived from this workshop was initially titled Cockpit Resource
Management, but this title was soon replaced by Crew Resource Management as study in
the field soon concluded that flight safety was under the influence of all crew, and indeed
all personnel in the aviation system, not only those on the flight deck.
Crew resource management may be defined as follows:
Question
What groups are involved with a single typical flight and the operating aircrew? Split into
two areas; within the airline/operator and outside the airline/operator.
Answer
Background to CRM
Slide – Early technology
In the days of early technology, human error was the cause of many safety related
incidents.
Extensive study has been applied to the causal factors of aviation accidents; research has
been carried out by:
From this research human performance has been cited as the causal factor in the majority
of accidents. It is generally accepted that greater than 75% of accidents have human error
as a major factor.
In recent years the study and application of an error avoidance programme within the
aviation industry called Crew Resource Management (CRM), has become mandatory for
many Civil and Military aircraft operations worldwide.
Aviation uses error management strategies to improve safety. Error management is based
on:
Understanding the nature and extent of error/risk.
Changing the conditions that induce error.
Determining the behaviours that prevent or mitigate error.
In the early years of commercial aviation the captain was considered the only important
individual involved in flight safety. The stereotypical captain was a white scarfed, goggled
pilot who had such personality traits as independence, macho, bravery and individualism.
As aircraft grew larger and operations grew more complex and demanding, a co-pilot was
added to the flight crew. The first co-pilots were considered redundant pilots. Their
function was simply to provide an operational backup in the rare event that the captain
became incapacitated, and to provide support and reduce the workload for the captain if
they were asked to do so.
Initially many captains did not like the idea and for several years the co-pilot did little more
than make out the flight plans for the captain to approve and sign and handle the radio
communications.
In the 1980’s as accidents and incidents were evaluated, it became clear that the
technical ability of the crew was very seldom the sole cause of the accidents and
incidents.
It appeared that frequently there was:
Less than optimum communication within the cockpit.
Crew interface problems that included:
Inadequate leadership.
Poor cockpit management.
Less than optimum group decision-making.
From 60 – 80% of aircraft hull loss accidents in commercial air transport have been
attributed to the flight crew for almost as long as records have been kept. Something
different had to be done. Despite improvements in the overall safety record, neither
industry nor regulatory efforts had been able to change the disheartening and
unsatisfactory relationship between accidents and the operational behaviour of the
cockpit crew.
Crew Resource Management was introduced by the UK CAA in 1993 for the practical
application of Flight Deck Management techniques. This was reinforced in 1995 for
recurrent training.
Pioneers Settlers
Make the Go with the
change change
When enough people make the change the sea-saw will tip.
If you have old dogs and well poisoners amongst your colleagues then their approach and
understanding of CRM needs to change. They need encouragement and awareness that
CRM has a very valid place in your operation. It is often those people who think they need
CRM the least that actually need it the most.
Other reasons for it not succeeding are perhaps:
Fear of failure
No one likes to make mistakes, and to have them looked down on by
someone else is a big fear. Adults take their mistakes to heart. Often
we would rather sweep them under the carpet and hide them.
CRM delivery methodology
Is it just a tick in the box exercise? Are the crew left on their own
watching a CRM video for an hour with no debrief and no discussion to
follow? Is the session delivered as pure instruction or is it a facilitated
session allowing the aircrew to input their opinions and thoughts.
The SHEL Model was originally conceived by Edwards in 1972, with the name derived from
the Initial letters of the components of the model (Software, Hardware, Environment, and
Liveware).
In 1975, Frank Hawkins (A KLM Captain) developed the concept into the ‘SHELL Model’
with the introduction of another Liveware into Edwards original SHEL Model.
The most pertinent difference between Edwards’s SHEL Model (1972) and Hawkins’s
SHELL Model (1975) is that Hawkins urged for the necessity of another ‘Liveware’ (the
person) and using diagrams, illustrated the interactions between the central Liveware and
each of the other four systems.
The SHELL Model now adopted by ICAO, is a useful and graphical aid to the understanding
of Human Factors, as it allows for a gradual approach to comprehension with a diagram
that can be built up incrementally to display the concept of the model using various blocks
to represent the different components of Human Factors. As each block is introduced the
need to match the components can be highlighted.
The following interpretations are suggested:
Environment The situation in which the S-H-L system must function. e.g.
noise, lighting, temperature, space , economic climate of
the industry etc.
In this model the match or mismatch of the blocks (interface) is just as important as the
characteristics of the blocks themselves. A mismatch can be a source of human error.
It should be mentioned that this building block diagram is only intended as a basic aid to
understanding Human Factors.
Slide – L (Liveware)
Liveware
In the centre of the model is a person, the most critical as well as the most flexible
component in the system.
People are subject to considerable variations in performance and suffer many limitations,
most of which are now predictable in general terms.
The edges of this block are not simple and straight, and so the other components of the
system must be carefully matched to them if stress in the system and eventual breakdown
are to be avoided.
In order to achieve this matching, an understanding of the characteristics of this central
component is essential. Some of the more important characteristics are the following:
Physical size and shape
This considers the design of the aircraft workplace and of most
equipment ranging from a flight deck seat through to a cabin crew meal
cart, a vital role is played by body measurements and movements,
which will vary according to age and ethnic and gender groups.
Decisions must be made at an early stage in the design process, and
the data for these decisions are available from anthropometry and
biomechanics.
Physical needs
This incorporates people's requirements for food, water and oxygen.
Data is available from physiology and biology.
Input characteristics
Humans have been provided with a sensory system for collecting
information from the world around them, enabling them to respond to
external events and to carry out the required task. But all senses are
subject to degradation for one reason or another and the sources of
knowledge here are physiology, psychology and biology.
Output characteristics.
Once information is sensed and processed, messages are sent to the
muscles to initiate the desired response, whether it is a physical control
Liveware–Environment interface
The human environment interface was one of the earliest recognised in flying.
Initially, the measures taken all aimed at adapting the human to the environment
(helmets, flying suits, oxygen masks, g-suits). Later, the trend was to reverse this process
by adapting the environment to match the human requirements (pressurisation, air
conditioning systems, soundproofing).
Today new challenges have arisen, notable ozone concentrations, radiation hazards at
high flight levels, problems associated with disturbed biological rhythms and related sleep
disturbance or sleep deprivation as a consequence of faster transmeridian travel. Other
environmental conditions may be weather induced turbulence.
Since illusions and disorientation are at the root of many aviation accidents, the L-E
interface highlights the need to consider perceptual errors induced by environmental
conditions, for example, illusions during approach and landing phases.
The aviation system also operates within the context of broad political and economical
constraints, and those aspects of the environment will also interact at this interface.
Although the possibility of modifying these influences is sometimes beyond Human Factors
practitioners, their incidence is critical to flight safety and should be properly considered
and addressed by those in management with the possibility to do so.
Causal factors
The following slide shows the top-ten individual primary causal factors allocated for all
fatal accidents, together with the causal group to which they belong.
These primary causal factors accounted for 59% of all fatal accidents and 80% of those
that had a primary causal factor allocated.
1. Loss of control
Through improved flight control monitoring, use of aircraft automation and manual flying
skills we are aiming to reduce the risk of loss of control occurrences.
2. Runway excursion
To help reduce the risk of runway excursions, we are aiming to reduce unstable/de-
stabilised approaches, improve information broadcast to pilots on expected braking action
on contaminated runways and improve safety areas around runways.
4. Runway incursion
We are actively promoting the European Action Plan for the Prevention of Runway
Incursions to reduce the risks of these occurring at UK aerodromes.
5. Airborne conflict
Through updating guidance on Airborne Collision Avoidance System (ACAS) training and
working with ICAO to amend their guidance, we aim to reduce the risk of mid-air collisions
associated with incorrect responses to ACAS warnings.
6. Ground handling
We are working with industry to raise awareness of the risks associated with ground
handling. The primary aim is to reduce the risks of incidents linked to loading errors.
7. Fire
We are developing training campaigns to raise fire safety awareness and to reduce the
risks of an in-flight hidden fire through a reduction of wiring related fire/smoke events.
References
1) CAP737 Crew Resource Management (CRM) Training.
Guidance for Flight Crew, CRM Trainers (CRMIs) and CRM Trainer-
Examiners (CRMIEs). UK CAA Safety Regulation group 31 March 2003
2) EASA Air Ops