1 Background

The entire package of Operator's Guide to Human Factors in Aviation relates to the wider concept of Crew Resource Management (CRM). This Briefing Note deals primarily with the “original” part of the CRM concept, namely the interaction between those involved in aviation, be they crew members, air traffic control, etc, as well as management of resources within the aviation environment.

Poor human interactions and poor management of resources have contributed to many accidents and incidents. This briefing note explores the problems that can be caused by poor interaction and coordination and provides a summary of the role that crew resource management (CRM) can play in preventing accidents and incidents.

The concept of CRM originated in the 1970s and was initially known as “cockpit resource management.” In essence, CRM is the practical application of the various aspects of human factors, including situational awareness, decision making, threat and error management (TEM), team cooperation and communication among the various people who are involved in the operation of flights. These include flight and cabin crews, maintenance personnel, air traffic controllers and dispatchers. The principles of CRM integrate both technical and nontechnical skills. As the name implies, CRM seeks to manage the available human resources effectively to reduce risk and maximize efficiency.

2 Introduction

Aviation is a complex, safety-critical environment in which an unsuitable action can lead to major consequences. Human error is the cause of approximately 80 percent of aviation accidents, and thus CRM is an important part of the defenses available to reduce the chances of errors and thereby improve flight safety.

The aviation industry is largely an international endeavor in which participants from diverse backgrounds must interact successfully if risk is to be minimized. The mix of cultures, ethnicities and nationalities in aviation can lead to situations in which misunderstanding and miscommunication can easily occur. Although often harmless and even comical, miscommunication and the failure to function as a team can represent a real threat to aviation safety if the task at hand demands a coordinated response. CRM was designed to foster coordination within the aviation team and to overcome differences in background, expectations and “style” that might otherwise tend to detract from effective teamwork.

Aviation authorities in many countries have mandated CRM training for pilots. Even in locales that do not require CRM training, many airlines have voluntarily introduced CRM training as part of their total training syllabus. It is widely recognized that good CRM training has the ability to prevent the poor interactions that are detrimental to safety. It has also become apparent that good CRM skills can improve productivity by promoting better understanding among people, a more amicable workplace and increased motivation to do the job correctly.

3 Discussion of Issues and Concepts

As indicated by the presence of “cockpit” in the original name, CRM initially focused just on the flight crew. Modern airline CRM training courses are often held jointly among pilots and cabin crew and sometimes even include ground staff such as dispatchers and engineers (maintenance technicians). This is a result of the realization that safety depends on the coordination of the key people in the entire system and not just on the actions of pilots. It also stems from evidence that a joint CRM course for flight and cabin crews can improve the level of understanding and cooperation across the entire team. This, in turn, has been recognized as beneficial in situations in which assistance to the flight crew from the cabin crew can help prevent an accident.

An example where good CRM would likely have helped involved an accident in which the wrong engine was shut down and the aircraft crashed during an attempted emergency landing. While one cause was clearly a deficiency in the technical knowledge of the flight crew, there was also a contributory CRM issue between the cabin and flight crews. There were doubts among the cabin crew and even the passengers about whether the correct engine was shut down, as they saw fire from the left engine, but the flight crew made an announcement about shutting down the right engine. However, these doubts were never communicated from the cabin to the cockpit. According to the report by the investigating authority, if one or more of the cabin crewmembers had taken the initiative to inform the flight deck of the observed fire in the left engine, this accident could have been prevented. One of the recommendations of the investigators was to introduce joint pilot and cabin crew training to improve CRM and coordination in response to an emergency.

In another serious accident, all three flight crewmembers became distracted by the absence of a landing gear “down and locked” indication on the panel. While trying to troubleshoot the landing gear problem, the crewmembers became distracted from the instruments and also did not notice the altitude warning sound. As a result, the positive delegation of aircraft control was not accomplished, and no one was flying the aircraft when it crashed. Investigators concluded that the probable cause of the accident was the crewmembers' preoccupation with the nose landing gear position indicator, which resulted in crew distraction that allowed the aircraft to descend unnoticed. Better CRM, in the form of positive task delegation and a clear understanding of whose responsibility it was to control the aircraft, would likely have prevented this accident. Avoidance of fixation (particularly from a relatively minor problem) would have been another likely benefit of good CRM in this scenario.

A number of CRM and human factors issues were reported as contributory in an accident where an aircraft taking off collided with one that was taxiing. These included miscommunication, misunderstanding and external pressure on the airport tower due to the closure of a nearby field. It is also possible that the large difference in experience between the captain (who was also the chief training captain) and first officer (who was relatively inexperienced in the aircraft type) of one of the aircraft made the first officer reluctant to intervene when the captain was rushing because he was close to his flight/duty time limits.

These are just a few examples of negative outcomes that could have been prevented if the involved crews had better CRM skills. It is important to learn from past accidents and incidents, and to use them to improve safety in the future.

It is also vital to understand that CRM skills are not something that can simply be read and learned. After training, they must be practiced, just as flying skills must be honed through practice after training.

4 Causes of Poor Management of Resources

One way to understand the potential benefits of CRM training is to examine common operational and personal factors that can lead to poor management of crew resources. These include:

• Lack of proper CRM training. In the absence of good training, crews may exhibit poor resource management and have an inadequate understanding of the value of CRM.
• Poor technical knowledge. Not having sound technical knowledge can affect one's performance adversely and also result in confusion, self-doubt, lack of confidence and credibility problems.
• The legacy of national culture. Some cultures may have very high authority gradients, making it difficult for a junior person to question the decisions and actions of a more senior person (e.g., a first officer being reluctant to speak up against a risky decision by the captain).
• Misunderstandings due to cultural, attitudinal or linguistic differences. Even when there is the intent to “get along,” these factors can lead to inadvertent resource management problems.
• Disruptive organizational culture. Some companies have a culture of discouraging people from speaking out. They may also place undue operational pressures on their flight crews that can lead to suboptimal decision making.
• Individual personality and attitude. Some people, by nature, do not want to listen to others and shun anyone who speaks up with an opinion contrary to theirs.
• Emotional status. A very negative experience, personal or occupational, can degrade resource management skills.
• Past experience. If someone experienced a bad result from speaking up and was chastised for it, that person may be less inclined to speak out again, even if he or she feels that the situation warrants it.
• Not appreciating the seriousness of the situation. Poor technical and/or human factors knowledge, as well as high workload and stress, can cause someone to misconstrue the gravity of events.
• Fatigue. Being tired can affect a person enough to turn a normally affable, cooperative person into someone who is very difficult to deal with. Fatigued individuals are also more prone to fixations, low situational awareness and poor decision making.
• Poor attitude. If someone has an inflated view of himself, his resource management will likely suffer. For example, believing one is almost invincible or infallible makes it difficult to work as a member of a team.
• Excessive emphasis on technical expertise to the detriment of the human aspects of flying. Accurate technical knowledge is important to have, but it is not a replacement for good resource management skills. Some flying situations require teamwork as well as technical skills.
• A “them and us” attitude toward other aviation workers. Teamwork is built on mutual respect. Pilots certainly have a safety-critical job, but they cannot perform it effectively without help from the other team members.
• Prejudices against people. If someone has a negative attitude toward another person because of factors such as his or her background, culture or gender, it is less likely that interactions with that person will be positive.

5 Preventing Unsafe Conditions Caused by Poor Resource Management Skills

Fortunately, there are many ways of countering the factors described above and thereby preventing unsafe conditions caused by poor resource management. These include:

• Good background knowledge and understanding of human factors and safety. Understanding how people work and interact is an important prerequisite for managing crew resources.
• A good CRM training course. Such a course should cover situational awareness, decision making, threat and error management, teamwork (including communication, cooperation, leadership and followership), human-machine interaction and automation.
• Sound English language skills. This is particularly important in a multicultural environment because English is the common language of aviation.
• Awareness of one's own national or organizational leanings. For instance, if you are working for a particularly hierarchical organization with a very high authority gradient where you are discouraged from speaking out to your seniors, you need to make a conscious effort to speak out when safety may be at stake.
• Awareness of one's own tendencies and attitudes. For instance, if you tend to take offense at having someone tell you that he or she does not agree with you, you may need to rethink your reactions and make particular efforts to be more accepting about listening to differing opinions.
• Proper planning and briefing, and not deviating from standard operating procedures (SOPs). This will reduce the chance of a misunderstanding.
• Improved technical knowledge and expertise. This will help you deal more confidently with many situations without becoming overloaded. It will also permit you to work on a problem with others in a less defensive manner if your opinion is questioned.
• Awareness of other people's cultures, backgrounds and attitudes. Awareness is a vital step in developing a better and more tolerant understanding of other people.
• Do not assume that other people have the same thought process, opinions or cultural leanings as you do. Everyone is different, and the way you do things or the way you think is not the only “right” way. Be assertive but, at the same time, remain open and recognize the potential for legitimate differences.
• Do not assume that other people have noticed a problem. If it is not absolutely clear that they have noticed it, point it out to them diplomatically and respectfully.
• Do not succumb to operational pressure if doing so may compromise safety. Be aware that operational pressure can influence your decisions, and be alert for any adverse effects from them. If in doubt, speak out.
• Do not be afraid to ask for help. Use all available resources, and do not make the problem worse by keeping it to yourself.
• If you make an error or a wrong decision, do not be embarrassed about admitting it. Errors can be managed before they result in something serious. But, if you hide it from others, they will not be able to contribute to dealing with it successfully. Also, think about why the error occurred and about how you can prevent it next time.
• Practice better decision making and communication in your daily life. Focus on maintaining maximum situational awareness. You do not need to be aviating to practice those things.
• If you identify shortcomings in your own behavior, have a trusted friend keep his or her eye on you and point out to you when you do something undesirable. It will help you to know what you are doing and how you are improving. It does not matter where you do this. It does not even have to be related to aviation.
• Do not be prejudiced against others. Be respectful toward others and embody the spirit of teamwork.
• Remember, the common goal of all aviation professionals is safety. You and everyone you work with must share the desire and objective of doing the job safely and contributing to better aviation safety records.

6 Key Points

• Aviation is a complex, evolving, safety-critical industry where it is necessary to work as a team in order to reduce the potential for unsafe situations.
• Poor resource management skills have contributed to many aviation accidents.
• Because aviation is an international industry in which diverse cultures may interact, it is particularly important that everyone involved has a good set of resource management skills.
• Poor resource management can be caused by a wide variety of factors, including poor technical knowledge, cultural differences, fatigue and bad attitudes.
• There are many things that can be done to improve resource management skills. These include formal training courses, self-education, becoming more aware of one's own culture, personality and attitudes, and generally practicing better communication in daily life.

7 Associated OGHFA Material

All of the briefing notes and situational examples are, in one way or another, relevant to CRM. Therefore, it is recommended that they be used as appropriate.

8 Additional Reading Material

• Flight Safety Foundation Approach and Landing Accident Reduction (ALAR) Toolkit
• Accident/incident reports produced by the various investigation bodies around the world (e.g., U.S. NTSB, the U.K. Air Accidents Investigation Branch, French Bureau d’Enquêtes et d’Analyses, Transportation Safety Board of Canada, Australian Transport Safety Bureau, etc.).

Related SKYbrary Articles

• Crew Resource Management (CRM)
• Accident and Serious Incident Reports by SKYbrary Category