Crew resource management

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Crew resource management or cockpit resource management (CRM) [1] [2] is a set of training procedures for use in environments where human error can have devastating effects. CRM is primarily used for improving aviation safety and focuses on interpersonal communication, leadership, and decision making in aircraft cockpits. Its founder is David Beaty, a former Royal Air Force and a BOAC pilot who wrote "The Human Factor in Aircraft Accidents" (1969). Despite the considerable development of electronic aids since then, many principles he developed continue to prove effective.

Contents

CRM in the US formally began with a National Transportation Safety Board (NTSB) recommendation written by NTSB Air Safety Investigator and aviation psychologist Alan Diehl [3] during his investigation of the 1978 United Airlines Flight 173 crash. The issues surrounding that crash included a DC-8 crew running out of fuel over Portland, Oregon, while troubleshooting a landing gear problem. [4]

The term "cockpit resource management"—which was later generalized to "crew resource management"—was coined in 1979 by NASA psychologist John Lauber, who for several years had studied communication processes in cockpits. [5] While retaining a command hierarchy, the concept was intended to foster a less-authoritarian cockpit culture in which co-pilots are encouraged to question captains if they observed them making mistakes. [5]

CRM grew out of the 1977 Tenerife airport disaster, in which two Boeing 747 aircraft collided on the runway, killing 583 people. A few weeks later, NASA held a workshop on the topic, endorsing this training. [6] In the US, United Airlines was the first airline to launch a comprehensive CRM program, starting in 1981. [7] By the 1990s, CRM had become a global standard. [5]

United Airlines trained their flight attendants to use CRM in conjunction with the pilots to provide another layer of enhanced communication and teamwork. Studies have shown the use of CRM by both work groups reduces communication barriers and problems can be solved more efficiently, leading to increased safety. [8] CRM training concepts have been modified for use in a wide range of activities including air traffic control, ship handling, firefighting, and surgery, in which people must make dangerous, time-critical decisions. [9]

Overview

The current generic term "crew resource management" (CRM) has been widely adopted but is also known as cockpit resource management; flightdeck resource management; and command, leadership and resource management. When CRM techniques are applied to other arenas, they are sometimes given unique labels, such as maintenance resource management, bridge resource management, or maritime resource management.

CRM training encompasses a wide range of knowledge, skills, and attitudes including communications, situational awareness, problem solving, decision making, and teamwork; together with all the attendant sub-disciplines which each of these areas entails. CRM can be defined as a system that uses resources to promote safety within the workplace.

CRM is concerned with the cognitive and interpersonal skills needed to manage resources within an organized system rather than with the technical knowledge and skills required to operate equipment. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork. In many operational systems, skill areas often overlap, and are not confined to multi-crew craft or equipment, and relate to single operator equipment or craft.

Aviation organizations including major airlines and military aviation have introduced CRM training for crews. CRM training is now a mandated requirement for commercial pilots working under most regulatory bodies, including the FAA (US) and EASA (Europe). The NOTECHS system is used to evaluate non-technical skills. Following the lead of the commercial airline industry, the US Department of Defense began training its air crews in CRM in the mid 1980s. [10] The U.S. Air Force and U.S. Navy require all air crew members to receive annual CRM training to reduce human-error-caused mishaps. [11] [12] The U.S. Army has its own version of CRM called Aircrew Coordination Training Enhanced (ACT-E). [13]

Case studies

United Airlines Flight 173

When the crew of United Airlines Flight 173 was making an approach to Portland International Airport on the evening of Dec 28, 1978, they experienced a landing gear abnormality. The captain decided to enter a holding pattern so they could troubleshoot the problem. The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply, and only realized the situation when the engines began flaming out. The aircraft crash-landed in a suburb of Portland, Oregon, over six miles (10 km) short of the runway. Of the 189 people aboard, two crew members and eight passengers died. The NTSB Air Safety Investigator Alan Diehl wrote in his report:

Issue an operations bulletin to all air carrier operations inspectors directing them to urge their assigned operators to ensure that their flightcrews are indoctrinated in principles of flightdeck resource management, with particular emphasis on the merits of participative management for captains and assertiveness training for other cockpit crewmembers. (Class II, Priority Action) (X-79-17) [3]

Diehl [3] was assigned to investigate this accident and realized it was similar to several other major airline accidents including the crash of Eastern Air Lines Flight 401 [14] and the runway collision between Pan Am and KLM Boeing 747s at Tenerife. [15]

United Airlines Flight 232

Captain Al Haynes, pilot of United Airlines Flight 232, credits CRM as being one of the factors that saved his own life, and many others, in the Sioux City, Iowa, crash of July 1989:

 ... the preparation that paid off for the crew was something ... called Cockpit Resource Management ... Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said, goes. And we lost a few airplanes because of that. Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about. And we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced [under those failure conditions], any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn't used [CRM], if we had not let everybody put their input in, it's a cinch we wouldn't have made it. [16]

Air France 447

One analysis blames failure to follow proper CRM procedures as being a contributing factor that led to the 2009 fatal crash into the Atlantic Ocean of Air France Flight 447 from Rio de Janeiro to Paris. The final report concluded the aircraft crashed after temporary inconsistencies between the airspeed measurements—likely due to the aircraft's pitot tubes being obstructed by ice crystals—caused the autopilot to disconnect, after which the crew reacted incorrectly, causing the aircraft to enter an aerodynamic stall from which it did not recover. [17]

Following recovery of the black box two years later, independent analyses were published before and after the official report was issued by the BEA, France's air safety board. One was a French report in the book "Erreurs de Pilotage" written by Jean-Pierre Otelli, [18] [19] [20] [21] which leaked the final minutes of recorded cockpit conversation. According to Popular Mechanics , which examined the cockpit conversation just before the crash:

The men are utterly failing to engage in an important process known as crew resource management, or CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, and who is doing what. [17]

First Air Flight 6560

The Canadian Transportation Safety Board (CTSB) determined a failure of Crew Resource Management was largely responsible for the crash of First Air Flight 6560, a Boeing 737-200, in Resolute, Nunavut, on August 20, 2011. A malfunctioning compass gave the crew an incorrect heading, although the instrument landing system and Global Positioning System indicated they were off course. The first officer made several attempts to indicate the problem to the captain but a failure to follow airline procedures and a lack of a standardized communication protocol to indicate a problem led to the captain dismissing the first officer's warnings. Both pilots were also overburdened with making preparations to land, resulting in neither being able to pay full attention to what was happening.

First Air increased the time dedicated to CRM in their training as a result of the accident, and the CTSB recommended regulatory bodies and airlines to standardize CRM procedures and training in Canada. [22] [23] [24] [25] [26]

Qantas Flight 32

The success of the Qantas Flight 32 flight has been attributed to teamwork and CRM skills. [27] Susan Parson, the editor of the Federal Aviation Administration (FAA) Safety Briefing wrote; "Clearly, the QF32 crew's performance was a bravura example of the professionalism and airmanship every aviation citizen should aspire to emulate". [28]

Carey Edwards, author of Airmanship wrote:

Their crew performance, communications, leadership, teamwork, workload management, situation awareness, problem solving and decision making resulted in no injuries to the 450 passengers and crew. QF32 will remain as one of the finest examples of airmanship in the history of aviation. [29] [30]

Adoption in other fields

Transportation

The basic concepts and ideology of CRM have proven successful in other related fields. In the 1990s, several commercial aviation firms and international aviation safety agencies began expanding CRM into air traffic control, aircraft design, and aircraft maintenance. The aircraft maintenance section of this training expansion gained traction as Maintenance Resource Management (MRM). To attempt to standardize the industry-wide CRM training, the FAA issued Advisory Circular 120–72, Maintenance Resource Management Training [31] in September 2000.

Following a study of aviation mishaps between 1992 and 2002, the United States Air Force determined close to 18% of its aircraft mishaps were directly attributable to human error in maintenance, [32] which often occurred long before the flight in which the problems were discovered. These "latent errors" include failures to follow published aircraft manuals, lack of assertive communication among maintenance technicians, poor supervision, and improper assembly practices. In 2005, to address these human-error-induced aircraft mishaps, Lt Col Doug Slocum, Chief of Safety at the Air National Guard's (ANG) 162nd Fighter Wing, Tucson, directed the modification of the base's CRM program into a military version called Maintenance resource management (MRM).[ citation needed ]

In mid-2005, the Air National Guard's Aviation Safety Division converted Slocum's MRM program into a national program available to the Air National Guard's flying wings in 54 U.S. states and territories. In 2006, the Defense Safety Oversight Council (DSOC) of the U.S. Department of Defense (DoD) recognized the mishap-prevention value of this maintenance safety program by partially funding a variant of ANG MRM for training throughout the U.S. Air Force. This ANG initiated, DoD-funded version of MRM became known as Air Force Maintenance Resource Management (AF-MRM) and is now widely used in the U.S. Air Force. [33]

The Rail Safety Regulators Panel of Australia has adapted CRM to rail as Rail Resource Management and developed a free kit of resources. [34] Operating train crews at the National Railroad Passenger Corporation (Amtrak) in the United States are instructed on CRM principles during yearly training courses.[ citation needed ]

CRM has been adopted by merchant shipping worldwide. The STCW Convention and STCW Code, 2017 edition, [35] published by the I.M.O. states the requirements for Bridge Resource Management and Engine Room Resource Management training. These are approved shore-based training, simulator training, or approved in-service experience. Most maritime colleges hold courses for deck and engine room officers. Refresher courses are held every five years. These are referred to as Maritime resource management.

Firefighting

Following its successful use in aviation training, CRM was identified as a potential safety improvement program for the fire services. Ted Putnam advocated for improved attention to human factors that contribute to accidents and near misses, building on CRM principles. [36] In 1995, Dr. Putnam organized the first Human Factors Workshop for wildland fire. [37] [36] Dr. Putnam also wrote a paper that applied CRM concepts to the violent deaths of 14 Wildland firefighters on the South Canyon Fire in Colorado.[ citation needed ]

From this paper, a movement was initiated in the Wildland and Structural Fire Services to apply CRM concepts to emergency response situations. Various programs have since been developed to train emergency responders in these concepts and to help track breakdowns in these stressful environments.[ citation needed ]

The International Association of Fire Chiefs published its first CRM manual for the fire service in 2001. It is currently[ when? ] in its third edition. [38] Several industry-specific textbooks have also been published.[ citation needed ]

Healthcare

Elements of CRM have been applied in US healthcare since the late 1990s, specifically in infection prevention. For example, the "central line bundle" of best practices recommends using a checklist when inserting a central venous catheter. The observer checking off the checklist is usually lower-ranking than the person inserting the catheter. The observer is encouraged to communicate when elements of the bundle are not executed; for example if a breach in sterility has occurred. [39]

TeamSTEPPS

The Agency for Healthcare Research and Quality (AHRQ), a division of the United States Department of Health and Human Services, also provides training based on CRM principles to healthcare teams. This training, called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and the program is currently[ when? ] being implemented in hospitals, long-term care facilities, and primary care clinics around the world. [40] TeamSTEPPs was designed to improve patient safety by teaching healthcare providers how to better collaborate with each other by using tools such as huddles, debriefs, handoffs, and check-backs. [41] [40] Implementing TeamSTEPPS has been shown to improve patient safety. [42] There is evidence TeamSTEPPS interventions are difficult to implement and are not universally effective. [41] There are strategies healthcare leaders can use to improve their chance of implementation success, such as using coaching, supporting, empowering, and supporting behaviors. [43]

See also

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References

  1. ↑ Diehl, Alan (2013). Air Safety Investigators: Using Science to Save Lives – One Crash at a Time. ISBN   9781479728930.
  2. ↑ Capt. Al Haynes (May 24, 1991). "The Crash of United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff.
  3. 1 2 3 "Air Crash Investigation: Focused on Failure", Discover Channel/National Geographic Program "Mayday"S12 E08
  4. ↑ "United Flight 232." Retrieved 2007-03-27. Presentation to NASA Dryden Flight Research Facility staff.
  5. 1 2 3 Langewiesche, William (October 2014). "The Human Factor". Vanity Fair . Retrieved September 25, 2014.
  6. ↑ Cooper, G. E., White, M. D., & Lauber, J. K. (Eds.) 1980. "Resource management on the flightdeck," Proceedings of a NASA/Industry Workshop (NASA CP-2120).
  7. ↑ Helmreich, R. L.; Merritt, A. C.; Wilhelm, J. A. (1999). "The Evolution of Crew Resource Management Training in Commercial Aviation" (PDF). International Journal of Aviation Psychology . 9 (1): 19–32. CiteSeerX   10.1.1.526.8574 . doi:10.1207/s15327108ijap0901_2. PMID   11541445. Archived from the original (PDF) on March 6, 2013.
  8. ↑ Ford, Jane; Henderson, Robert; O'Hare, David (February 2014). "The Effects of Crew Resource Management Training on Flight Attendants' Safety Attitudes". Journal of Safety Research. 48: 49–56. doi:10.1016/j.jsr.2013.11.003. PMID   24529091.
  9. ↑ Diehl, Alan (June, 1994). "Crew Resource Management...It's Not Just for Fliers Anymore". Flying Safety, USAF Safety Agency.
  10. ↑ Diehl, Alan (November 5, 1992) "The Effectiveness of Civil and Military Cockpit Management Training Programs." Flight Safety Foundation, 45th International Air Safety Seminar, Long Beach, CA.
  11. ↑ "Air Force Instruction 11-290" (PDF). Department of the Air Force. April 11, 2001. Archived from the original (PDF) on May 27, 2011. Retrieved December 7, 2007.
  12. ↑ "OPNAVINST 1542.7C" (PDF). Department of the Navy, Office of the Chief of Naval Operations. October 12, 2001. Archived from the original (PDF) on July 22, 2011. Retrieved March 14, 2011.
  13. ↑ Brown, Douglas. "ACT-E Update". Knowledge. US Army Safety Center. Archived from the original on October 13, 2013. Retrieved October 12, 2013.
  14. ↑ NTSB report: Eastern Airlines, Inc, L-1011, N310EA, Miami, Florida, December 29, 1972, NTSB (report number AAR-73/14), June 14, 1973
  15. ↑ International Civil Aviation Organization, Circular 153-An/56, Mortreal, Canada, 1978)
  16. ↑ Capt. Al Haynes (May 24, 1991). "The Crash of United Flight 232". Archived from the original on October 26, 2013. Retrieved June 4, 2013. Presentation to NASA Dryden Flight Research Facility staff.
  17. 1 2 Wise, Jeff (June 1, 2020). "What Really Happened Aboard Air France 447". Popular Mechanics.
  18. ↑ Vigoureux, Thierry (February 15, 2012). "AF447, pas de diffamation pour". Le Point.
  19. ↑ "A controversial look at the crash of flight 447". The Economist. October 14, 2011.
  20. ↑ Allen, Peter (October 13, 2011). "Final words of Air France passenger jet emerge: 'what's happening?'" – via www.telegraph.co.uk.
  21. ↑ Clark, Nicola (November 20, 2011). "When Disaster Threatens, Instinct Can Be a Pilot's Enemy". The New York Times.
  22. ↑ "First Air captain ignored co-pilot's warnings before Nunavut crash". CBC News. October 3, 2013. Retrieved June 27, 2020.
  23. ↑ "Poor training, miscommunication, simple accident led to 2011 Nunavut air disaster". Nunatsiaq News. March 26, 2014.
  24. ↑ "Co-pilot suggested at least twice to change course before deadly First Air flight 6560 crash: TSB". APTN National News. March 25, 2014.
  25. ↑ Transportation Safety Board of Canada (March 5, 2014). "Aviation Investigation Report A11H0002". www.tsb.gc.ca. Government of Canada.
  26. ↑ Carlson, Kathryn Blaze (March 25, 2014). "Combination of factors blamed for fatal Resolute Bay plane crash". The Globe and Mail.
  27. ↑ "CRM at its best: Qantas flight 32, learning from the recent past". January 10, 2017.
  28. ↑ "aviation citizenship" (PDF). www.faa.gov. 2013. Retrieved June 27, 2020.
  29. ↑ "Book Reviews". December 1, 2012.
  30. ↑ Edwards, Carey (2008). Airmanship. Crowood Press UK. ISBN   9781861269805 – via Google Books.[ page needed ]
  31. ↑ FAA AC 120-72: http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/3e5ec461ecf6f5e886256b4300703ad1/$FILE/AC%20120-72.pdf Archived August 6, 2010, at the Wayback Machine
  32. ↑ "Air Force Safety Center". September 2000. Archived from the original on June 24, 2003.
  33. ↑ Air Force MRM: "Situational Awareness: The Ability to Maintain the Big Picture". U.S. Air Force Maintenance Resource Management. Archived from the original on June 30, 2007. Retrieved February 21, 2009.
  34. ↑ Office of the National Rail Safety Regulator (September 7, 2021). "Rail resource management". onrsr.com.au. Archived from the original on March 12, 2022. Retrieved March 27, 2022.
  35. ↑ STCW Including 2010 Manila Amendments, 2017 Edition. Published by the International Maritime Organization ISBN   9789280116359 Pages 104 and 145
  36. 1 2 Miller, Bill (December 7, 2004). "Leaders We Would Like to Meet: Interview with Ted Putnam" (PDF). Wildland Fire Leadership Development Program. Retrieved April 22, 2023.
  37. ↑ Putnam, Ted (November 1995) [Updated July 1996]. "Findings from the Wildland Firefighters Human Factors Workshop. 9551-2855-MTDC" (PDF). Rocky Mountain Research Station, USDA-USFS. Retrieved April 21, 2023.
  38. ↑ "Crew Resource Management". www.iafc.org.
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  40. 1 2 U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research; http://teamstepps.ahrq.gov/aboutnationalIP.htm
  41. 1 2 Stewart, Greg L.; Manges, Kirstin A.; Ward, Marcia M. (2015). "Empowering Sustained Patient Safety". Journal of Nursing Care Quality. 30 (3): 240–246. doi:10.1097/ncq.0000000000000103. PMID   25479238. S2CID   5613563.
  42. ↑ Sawyer, Taylor; Laubach, Vickie Ann; Hudak, Joseph; Yamamura, Kelli; Pocrnich, Amber (January 1, 2013). "Improvements in Teamwork During Neonatal Resuscitation After Interprofessional TeamSTEPPS Training". Neonatal Network. 32 (1): 26–33. doi:10.1891/0730-0832.32.1.26. PMID   23318204. S2CID   9468204.
  43. ↑ Manges, Kirstin; Scott-Cawiezell, Jill; Ward, Marcia M. (January 1, 2017). "Maximizing Team Performance: The Critical Role of the Nurse Leader". Nursing Forum. 52 (1): 21–29. doi: 10.1111/nuf.12161 . ISSN   1744-6198. PMID   27194144.
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