Unit 2
Unit 2
It has been widely quoted during the past several decades that around 75% of
accidents are caused by human error but what this term fails to recognize is that
humans are but one part of the wider environment – they must interact with
many components including weather, technology, social systems etc. Despite
this, humans are at the most very basic level the root cause of almost every
incident because humans ultimately design and/or interact with all elements of
the wider environment.
The core reason for the existence of air carriers is to safely transport people and
goods from one place to another. Management of risk and threat is the key to
managing safety and therefore many aviation systems (such as weather
planning, air traffic control and flight deck warning systems) exist to manage
risk.
Modern crew resource management focuses upon the management of all
available resources to reduce error including all groups of aviation specialists
(e.g. air traffic controllers, pilots, cabin crewmembers, mechanics and
dispatchers) through goal setting, teamwork, awareness and both pro- and
reactive feedback (Helmreich).
Awareness of the current state of both internal (onboard the aircraft) and
external operations (air traffic instructions, environment, weather) and
threats
Threat detection (through awareness of the situation),
Threat response through expertise (training/standard operating
procedures), coordination and communication (between the crew and air
traffic control, intra-crew, crew and dispatch etc),
The situation posed here presents several threats to the flight (weather,
demands of ATC, schedul adherence)
The flight crew detects these threats using the core elements of monitoring
and expertise (recognizing the bad weathers impact through awareness of the
environment and their expertise of meteorology, air traffic control and their
training in CRM/human factors).
These threats have been detected and the flight crew responds to the
threat using the throughputs of situational awareness, expertise,
communication/cooperation (teamwork) and feedback.
Awareness of the current state of the threats and the situation (state of the
aircraft in relation to fuel, capabilities and where the aircraft is in relation
to other traffic and the flight plan)
Expertise is used to manage the threats through the flight crew’s
knowledge of the situation and options available to manage it – e.g.,
diverting, holding
Communication/cooperation between the flight crew, dispatch, ATC,
cabin crew is used to discuss threats, formulate a plan of action and
various options available to the flight.
Feedback on how the plan of action is working
Safety of the flight (i.e. decision to only make one approach and divert if
unsuccessful) is the outcome.
One of the most outstanding developments in aviation safety for the past decade
has been the implementations of training programs aiming to increase
effectiveness and efficient in crew’s teamwork as well as flight-deck
management (Foushee & Helmreich 1993). This development was first
introduced when aircraft investigators concluded that ‘pilot error’ documented
in past accidents and incidents were reflected to team-communication and
coordination rather then pilots ‘stick and rudder’ skills proficiency (Murphy
1980). The original label for such training was known as cockpit resource
management, but with recognition to its applicability of the approach to others
members of the aviation community; it changes into Crew Resource
Management (CRM) (Helmreich, Merritt & Wilhelm 1999).
Communication
Workload Management
Decision-making
Conflict Resolution
Leadership
Team Management
Stress Management
On 25th January 1990, Avianca Flight 052 crashed while making a second
attempt to land at JFK International Airport, New York (NTSB aircraft accident
report HK2016). NTSB reported that flight crew did not communicate an
emergency fuel situation to the ATC before fuel exhaustion occurred.
Communications was reported as not clear and the captain did request the first
officer to repeat information louder as the captain could not hear it. A fatal
communication error occurs when the first officer relay the message to turn
starboard instead of turning port. This massage made the B707-321B fly a
longer loop thus burning more fuel. Communications between the ATC and the
first officer clearly shows a misinterpretation about fuel level. The first officer
assumed that the ATC had acknowledged the low fuel status of the Flight 052
but in fact, the ATC interpreted the transmission as ‘Flight 052 has sufficient
fuel’. Words like ‘emergency’ was not used by the first officer thus it leads to a
different outcome of interpretation.
The second clusters of skills will be Team Building. Team building consists of
two major concepts which are leadership and team management. Large aircrafts
like the A380s or the B747-800s are flown by teams not by individual pilots.
Teams are often used in aviation as the complexity of task increases as
technology advances. Teams are used to also provide redundancy in order to
provide an extra safety factor which is critical for aviation (Ginnett 1993). CRM
focus on how people behave in teams/groups. As people behave differently in
teams/groups as they do alone, CRM training teaches personnel to adapt to such
situations and to optimise performance rather then getting ‘affect’ from team-
working. CRM aims to reduce problems which might be created in teams such
as, bystander effect, conformity, social loafing, decision-making in teams and
groupthink (Jensen 1995).
This Example display how poor team performance can have disasters
consequences. Conformity affects the co-pilot as he agrees with the captain to
allow unauthorised personnel to handle the aircraft. The co-pilot knew that this
was against procedure and worst of all; to let someone without any
qualifications on flying to handle the aircraft. The co-pilot was perhaps under
pressure from the captain when he gave in towards the decision. Normative-
influence occurs in order to not to offend the captain. In another aspect, the
captain did not show leadership capabilities as he had breech safety policies to
allow non-pilots to fly the commercial airliner.
If the co-pilot had been properly trained with CRM, he would reject the
captain’s idea. CRM teaches a person to use proper communication skills as
well as assertive behaviour in order to handle such situations. Therefore, from
this example, we can conclude that CRM is critical and it will be able to prevent
such fatal accidents.
Workload.
These include concepts like mission planning, stress management and workload
distribution. Accidents often happen when workload demands are greater than
team capabilities. In pilot’s perspective, most accidents happen during take-off
and landing phrases. These phrases are periods on high workload. But
surprisingly, low workload can also cause accidents. In flight crew perspective,
during the long cruise segments, the pilots may be less attentive then when they
are working frantically. This low workload periods are times where
complacency is the most common. This is known as the low-arousal level factor
from the Yerkes-Dowson Law (Wickens & Hollands 2000).
On 3rd September 1989 2045hour, VARIG airline flight RG 254 made a forced
landing into a jungle near Sao Jose do Xingu, Brazil due to fuel exhaustion
(ICAO Adrep Summary 5/89 #11). The flight, a B737-241 took off at 1725hour
from Maraba towards Belem, Brazil. The flying time was approximately
45mins. The flight crew entered into the flight computer 270degrees instead of
027degrees. After 2hours of flying, the captain finally realized that they were
flying towards the wrong direction. Amendments were made to fly back to their
original route, but it was too late. The plane was 600NM off course.
Fuel exhaustion occurred which leads to the forced landing in the jungle. The
navigation mistake went unnoticed because the flight crews were reported
listening to the World Cup Qualification Match between Brazil vs. Chile.
From this example, we can see that how poor workload management contributes
to such an accident. If the crew/team manages to priories their workload and if
the crew doubled-check their computer inputs, such accidents will not even
occur. With quality CRM training, teams are train to follow procedures and to
double-check their work. Good leaders will distribute even workload to each
member’s capacity, in order to have optimal performance. From this accident, if
captain has ordered the co-pilot to make scheduled checks on the flight
computer, such accidents could be prevented. Distractions such as listening to
radios should be minimised. The pilots should increase their arousal level by
going through cruising procedures in order to have optimal performance during
cruising. CRM training for personnel will prevent such accidents which
increases aviation’s safety.
From the three examples given above which demonstrated human factors being
a key failure which result in massive destruction, proper CRM training must be
applied in order to increase safety in aviation. CRM knowledge will reduce the
above-mentioned slips/mistakes which will prevent the accidents.
The evolution of CRM training can be traced over three decades. CRM history
has been sub-divided into five generations (Foushee & Helmreich 1993).
The Second generation of CRM was held by NASA in 1986 (Orlady & Foushee
1987). By this time, there are many airlines conducting CRM programs. The
term ‘Crew ‘was used rather than ‘Cockpit’ as research believed that other
aviation personnel would require such skills as well. This also began adding
more skills into its core program such as team-building, decision-making.
Firstly, human factors topic added in to pilot training. Human factors have been
recognised as a ‘core technology’ in aviation. ICAO Assembly set the
foundation of human factor programs in 1986. In 1989, ICAO revise the
ANNEX 1 which from then all requires all contracting states pilots to be
familiar with ‘human performance and limitations’ In 1997, when the European
Joint Aviation Regulation (JARs) became effective, CRM is a mandatory all
professional pilots and those studying for their licenses (McAllister 1997). As
CRM evolves till today, it is recognised as a compulsory training for all pilots,
controllers and even other aviation personnel.
Secondly, with CRM regulation and its usefulness to reduce errors, aviation
training in airlines, flight schools, and military-flying has changed dramatically.
For example, airline pilots training is now focusing on training for technical
skills as well as behavioural and resource management skill in order to fly
safely and efficiently in today’s environment. Pilots are to know about human
strengths, limitations and small-group-performance in which they will take
advantage of them in which may reduce errors (Orlady 1993). CRM research
has also led to changes selection of pilots. Modern pilot selections are now
focusing on individual’s cognitive and psychomotor skills then their personality
factors.
CRM has now been an intangible topic in aviation training. It had actually
started two decades ago. CRM has been sub-divided in to five generations. It
evolves as a programme concern with only emphasizing on changing individual
styles and correcting deficiencies behaviour in the first generation, to the second
generation with more core skills like decision-makings. The term cockpit was
changed to crew at this point of era as they realised that other aviation
community require CRM training as well. The third generation has major
development such as including human factors concepts into its programme. The
fourth generation integrated organisational culture into its context. Till today,
the fifth generation of CRM training are still evolving and consistently
monitored for any changes to improve in safety. CRM training now shifted its
focus to limitation of human performance as compared to the first generation
which is psychological in nature.
As CRM research continues, many regulatory and government bodies such as
JARs, ICAO, NASA and FAA have all recognised the potential benefit of CRM
and they have implemented rules to include CRM and human factors as one of
its core modules for most aviation personnel training worldwide. CRM have
globalised into a necessity in aviation. Secondly, training for airliners, flight
schools and the military diverted their focus from mostly technical skills to an
even-mixture of technical and resource skills for pilots as well as other aviation
personnel. One major influence from CRM will be the selection process of
pilots in airlines as well as schools. Selection criteria shifted from personality
factor to applicants cognitive and psychomotor skills. With CRM training to
reduce errors, it directly means having more profits for airliners. Safety is
money. With less accident rate, airlines will cash in more money as compared to
the cost of an aircraft. With CRM trainings, they may in one way attract market-
share which allows airlines to earn more profit. CRM and other safety
programmes are actually cost-effective and would end up saving/earning
revenue for airliners.
To conclude, CRM training has evolved dramatically. It has helped the aviation
industry to be safer in all aspects of the industry. As error is inevitable, CRM
research will continue to change and grow with its aim to reduce more errors in
human performance in order rise to another level of aviation safety.
Over time, CRM has evolved and is now a global standard for the
aviation industry.
Situation awareness
Task allocation
Task allocation involves dividing up responsibilities among
teammates in order to accomplish goals effectively.
Decision-making
(2) CRM training is one way of addressing the challenge of optimizing the
human/machine interface and accompanying interpersonal activities. These
activities include team building and maintenance, information transfer, problem
solving, decisionmaking, maintaining situation awareness, and dealing with
automated systems. CRM training is comprised of three components: initial
indoctrination/awareness, recurrent practice and feedback, and continual
reinforcement.
Brief History of Crew
Resource Management
In the 1970s, a team of NASA researchers began evaluating the
performance of airline pilots, discovering that over 70 percent of airline
accidents were caused by human error. With the goal of reducing human-
caused errors in the cockpit, in 1979, the term, “cockpit resource
management”, was created by John Lauber, a research psychologist
working for the organization. Lauber developed the idea that crewmembers
needed to take a more team-oriented approach to flying.
Over time, CRM has evolved and is now a global standard for the aviation
industry.
Crew Resource
Management Goals
The primary purpose of CRM is to use all resources, including humans,
information and hardware, to mitigate errors and improve safety. According
to the FAA, “CRM training focuses on situation awareness, communication
skills, teamwork, task allocation and decision-making within a
comprehensive framework of standard operating procedures (SOP).” We’ll
dive into each of these.
Situation awareness