Crew Resource Management

Crew Resource Management as a Knowledge Management Tool in the Airline Industry

Lisa West LIS 880 Fall 2012

What is CRM?Crew Resource Management is the sharing of

knowledge and best practices to reduce errors and incidents.

Used by high reliability organizations (HROs):aviation, military, fire services, oil production,

nuclear operations, commercial shipping, medical field

CRM has been used by commercial airlines since 1981

HistoryInitiated by NASA in 1979

NASA discovered crashes due to lack of: Interpersonal communicationPoor decision makingLack of leadership skills

Evolution of CRM

United Airlines adopts CRM in 1981.

Used Blake and Mouton’s “Managerial Grid” concept: examine one’s managerial style

Training through lecture and non-jeopardy scenarios

1986 group dynamics emphasized: team building, decision making, situation awareness, stress management, “breaking the chain of errors”

Evolution of CRM

1990s grows to include pilots, flight attendants, dispatch, maintenance

Currently Federal Aviation Administration (FAA) Advanced Qualification Program (AQP) requires CRM to be incorporated into all aspects of training

Error management is a key component to CRM

Required by FAA and International Civil Aviation Organization (ICAO) for airlines in 185 countries

CRM ComponentsCommunication

Leadership Skills

Decision-making

Situation Awareness

Monitoring

Crosschecking

Understanding one’s limitation

CRM Components Social Skills

CooperationTeam building, team maintenance, considering and supporting

others, conflict resolution Leadership/Management Skills

Authority, standards maintenance, planning, coordination, workload management

Cognitive Skills Situation Awareness

Awareness of systems, the environment, and time Decision Making

Diagnosis of threat, problem resolution, risk assessment, result analysis

CRM TrainingInitial Training

LecturesCase study reviewAudio/visual materialPractical exerciseLine Oriented Flight Training (LOFT) role-playing

Annual re-training

Line Operation Safety Audits (LOSA)

LOSAReal life data collection

Flight deck crew actionsThreats and errorsThreat and error management

CRM skills evaluated and recorded

Strict “non-jeopardy” conditions

Data used for training development

StatisticsPoor CRM major contributor in Greek fatal

aviation accidents from1983 to 2003

60% of US Navy and Marine Corps. accidents from 1991 to 2000 involved CRM failure in cockpit.

Aviation Safety Reporting System (ASRS) reports 70% of incidents involved inadequate communication of information

General aviation crashes in Australia due to loss of situational awareness, a CRM skill

Statistics

98% of flights face threats

Errors occur on 82% of flights

70% decrease in crashes since the inception of CRM

Keys to CRM success

Operational and cultural shift

An environment that facilitates communication

Not a one-time fix, but continuing component of a safety culture

Trust in organization

Self-disclosure of information

Keys to CRM success

LOSA observations resulting in changes to Standard Operating Procedures (SOPs)

Sharing of information

Information management

Verbal cues among stakeholders

CRM Learning HistoryUnited Airlines flight 232

Sioux City, Iowa crash July 19, 1989

CRM cited by Captain Haynes and National Transportation Safety Board (NTSB) as major reason 185 of 296 people on board survived.

In 34 min. prior to crash, 31 pieces of communication per minute

NTSB cockpit voice recorder transcript

CRM Learning HistoryFlight 232 taught United Airlines CRM transfer of

knowledge saves lives

Was a benchmark of best practice in: Communication Leadership skills Decision-making Teamwork Situation awareness Monitoring Cross-checking Understanding one’s limitations

CRM Issues

No training standards

FAA and Civil Aviation Authority (CAA) support training through assistance and recommendations

Difficult to transfer to other cultures

CRM as cost reduction

Cost of commercial aviation accident$100 million Lost revenueLoss of employee productivityDisruption in routesPoor customer perceptionLoss of reputation

CRM as life saverCRM promotes teamwork

Discovers and reduces accidents and errors

Part of organizational learning

Creates benchmarks of best practices

Shares knowledge

Behavioral changes

SAVES LIVES!

Sources Aircraft Accident Report-United Airlines Flight 232, McDonnell Douglas DC-10-10, Sioux

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