Crew Resource Management
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Crew Resource Management

Critical Essays

Eduardo Salas, Eleana Edens, Katherine A. Wilson, Eduardo Salas, Eleana Edens, Katherine A. Wilson

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eBook - ePub

Crew Resource Management

Critical Essays

Eduardo Salas, Eleana Edens, Katherine A. Wilson, Eduardo Salas, Eleana Edens, Katherine A. Wilson

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About This Book

Crew Resource Management (CRM) training was first introduced in the late 1970s as a means to combating an increased number of accidents in which poor teamwork in the cockpit was a significant contributing factor. Since then, CRM training has expanded beyond the cockpit, for example, to cabin crews, maintenance crews, health care teams, nuclear power teams, and offshore oil teams. Not only has CRM expanded across communities, it has also drawn from a host of theories from multiple disciplines and evolved through a number of generations. Furthermore, a host of methodologies and tools have been developed that have allowed the community to better study and measure its effect on team performance and ultimately safety. Lacking, however, is a forum in which researchers and practitioners alike can turn to in order to understand where CRM has come from and where it is going. This volume, part of the 'Critical Essays on Human Factors in Aviation' series, proposes to do just that by providing a selection of readings which depicts the past, present, and future of CRM research and training.

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Publisher
Routledge
Year
2017
ISBN
9781351947718
Part I
History of Crew Resource Management
[1]
The Naval Safety Center’s Aircrew Coordination Training Program
Robert A. Alkov
Some unexpected side effects of the training have been reported by the squadrons that have had their “stand-up.” For the first time in some squadrons, RTS students and instructor pilots are talking to each other and discovering that there is a lack of standardization in their flight instruction.
[45] It was a dark, moonless night with no visible horizon. The SH-3 was on a low altitude training mission. Spotting what he thought was the landing light of an approaching P-3 aircraft, the HAC took the controls from the copilot and initiated evasive maneuvers resulting in a descending left turn from 450 feet AGL to water impact. The copilot, having read in NOTAMS that there was to be a flare drop that night, saw what he thought to be a flare, then began looking for the other traffic that the pilot reported. The RAWS tone was the first indication that the plane was descending, a second before impact, leaving no time to warn the pilot. The HAC started pulling collective when he saw 40 feet on the radar altimeter. This was the first time he had looked inside the aircraft since assuming control. Both pilots were looking for other traffic. The aircraft impacted the water and rolled over. One crewman drowned.
During the brief, specific details of cockpit responsibilities were never determined. The relaxed atmosphere established at the brief and lack of discussion of hazards and specific responsibilities set a tone in cockpit crew coordination that continued into the flight. The copilot apparently was unsure of what was expected of him during the flight. Had he informed the pilot that there was a scheduled flare drop and that what they were seeing looked like a flare, the pilot might have seen it for what it was, broken his fixation and recovered in time.
An A-6E on a night, low level systems attack flight, started its final run-in at 360 knots, 1,000 feet AGL. During the first minute, the aircraft accelerated from 370 KIAS to 440 KIAS. Realizing they were going to be early because the aircraft clock was out of synchronization with the range tower clock by eight seconds, the B/N asked the pilot to slow down. The LAWS warning, set for 900 feet, came on several times during this portion of the flight, but the pilot pulled back up to 1,000 feet each time – except the last. The last time it came on the tower was transmitting a message to the mishap aircrew. The B/N instructed the pilot to “slow down … quick.” The pilot put the speed brakes out and pulled the power to idle, slowing to 300 KIAS, setting up a high descent rate from which he didn’t recover. There was no ejection attempt as the aircraft impacted the target area, and the pilot and B/N were killed on impact.
Aircrew error accounted for 51 percent of the overall Navy/Marine Class A flight and flight-related mishap rate during the past 5½ calendar years (January 1983 through May 1988). During this same time, 54 percent of Class A flight and flight-related mishaps in Navy/Marine rotary-wing aviation were attributed to aircrew error. Of these helicopter aircrew mishaps, 62 percent had some degree of poor crew coordination, and in 9 percent, lack of situational awareness was a contributing factor. Another 24 percent could be attributed to poor judgment. For the EA-6 and A-6 aircraft communities, pilot error during the past 5½ years accounted for 52 percent of the Class A Flight /flight-related mishaps. Of these, 58 percent were related to poor aircrew coordination, 21 percent due to a loss of situational awareness, and 41 percent were due to poor pilot judgment. (These factors add up to more than 100 percent since there may be more than one human factor assigned in any one mishap.)
Flight experience, proficiency, life style and personality affect the quality of cockpit communications. Crew coordination is adversely affected where communications break down in the cockpit. Naval Flight Officers should be encouraged to offer verbal assistance, including opinions on mission parameters, regardless of the seniority of the pilot. Naval aviators must be impressed with the need to heed the inputs of their copilots and NFOs. Mission briefing must include a discussion of specific cockpit procedures and communication responsibilities.
With advances in aircraft design, maintenance procedures and standardized operations, aircraft have become more reliable. However, their aircrews, who are highly trained in dealing with programmed mechanical problems, are not preventing catastrophic aircraft accidents. Concentrating on cockpit human engineering design, better pilot training programs and improved NATOPS procedures has helped, but pilot factor mishaps continue to occur. Aircraft accidents tend to be attributed less to mechanical failure and more to human error. In recent years, there has been a growing realization of the significance of the lack of crew coordination and situational awareness as contributing factors to multi-crewed aircraft mishaps.
In the 1970s, researchers for NASA started conducting interviews of airline pilots. In exchange for confidentiality, [46] these pilots discussed their experiences during “near-miss” incidents. The object was to structure a meaningful research program to address some of the more perplexing problems that were the underlying factors causing so-called “pilot error” accidents. This interview program led to the Aviation Safety Reporting System (ASRS). Over a six-year period, 28,000 reports to ASRS were examined. It was found that 70 percent of these reports contained evidence of failures and breakdowns in communicating or relaying information. Based on these reports, in 1979, Dr. Pat Ruffell Smith, a psychologist working at NASA’s Ames Research Center, conducted a study of the interaction of pilots in a simulator. He concluded that high workload conditions can lead to a decrease in the performance of flight crews. Many of their problems related to the management of human and mechanical resources in the cockpit. The variability between crews in reacting to the same problems suggested to him that those who perform less well might be helped by special training. He went on to recommend that special training in resource management and leadership be developed and validated.
During the past several years, the FAA has held a series of workshops to assesss possible approaches to the growing problem. Many airlines voluntarily began to develop and teach courses for their crews on cockpit management, in the absence of any regulatory requirement. There are at least 16 well-established courses today, and many more are being proposed. The goal of the training is to improve management skills and the ability of each crew member to work in harmony with others. This is done by increasing every individual’s awareness of the impact that they can have on others, and how, with this recognition, they can more effectively interface with those with whom they come into contact. The ultimate objective is a more efficient, proficient and safe operation, which United Airlines defines as synergism in the cockpit. The program is based on a seminar format that provides role-playing opportunities for crew members to confront situations that are true to the experiences that occur on the line. Feedback on each individual’s effectiveness is provided by their fellow participants in the seminar.
In 1979, and again in 1987, NASA sponsored conferences on Cockpit Resource Management (CRM) Training. The 1987 conference was co-sponsored by the Military Airlift Command (MAC), which has embraced CRM training whole-heartedly. MAC uses their Mission Oriented Simulator Training (MOST) to teach crew coordination, decision making, and leadership and management skills in addition to systems knowledge, operating skills and aircraft handling. The US Army has developed a 19-step CRM package for rotary wing aircraft under the leadership of LtCol. Craig Geis (now retired). Colonel Geis’s program includes training in decision making, situational awareness, stress and fatigue, attitudes, workload assessment and time management, communications skills and conflict resolution in addition to standard CRM skills.
In 1984, responding to the lack of progress in further lowering the aircraft mishap rate, the Commander, Naval Safety Center tasked his staff to come up with ideas to enhance the Navy’s aviation safety posture, particularly in the area of human error. The Aeromedical Division of the Aviation Safety Directorate responded with a prospectus to develop a crew training package that would teach cockpit resource management skills to Naval aviation peronnel. A five-year program was proposed to the Naval Safety Center’s major claimant for funds, CNO (OP-09BF), starting with POM ’87. In August of 1986, the Commander, Naval Safety Center, wrote a personal letter to the DCNO (Air Warfare) stating that “Crew coordination problems, well documented in our helo communities, are beginning to appear with increased regularity in TACAIR.” The letter asked that all NATOPS model managers review their flight crew coordination section to develop improved standards. A conference was called at Headquarters, Marine Corps, and OPNAV during October-November 1986 to implement such a review.
At a workshop meeting of the Joint Aviation Safety Human Factors Subcommittee held at Fort Rucker, Ala., in November 1986, various experts in pilot decision making and aircrew coordination training outlined programs funded by the FAA and NASA to develop training materials for the airlines and general aviation. The Naval Safety Center drafted a statement of work for a training contract based on this data and the work reported on CRM during the Aviation Psychology Symposia series held at Ohio State University every other year since 1980. Materiao from the FAA and Transport Canada’s pilot judgment training program was also adopted.
Sponsored by CNO (OP-05) a trial program for helicopter fleet replacement training squadrons has now ended. A contract for developing such training was awarded to the Allen Corporation of America, a subsidiary of The Singer Company. HSL-30 at NAS Norfolk, and HSL-31 at NAS North Island, representing the LAMPS MK II group, were the first Navy squadrons to receive the training. The Marine CH-46 and CH-53 communities, represented by HMT-301 and HMT-302 at Marine Corps Air Station Tustin, Calif., and HMT-204 at Marine New River, Jacksonville, N.C., were the first Marine squadrons to receive this training. The UH-1/AH-1 FRS, HMT-303, at Camp Pendleton, was later included. Representing LAMPS Mark III, HSL-40 and 41 at NAF Mayport, and NAS North Island, respectively, have been trained. The SH-3 FRSs, HS-1 at NAS Jacksonville, Fla., and HS-10 at North Island also completed this training, while the H-46 squadron, HC-3 at North Island and the SAR Model Manager, HC-16 at NAS Pensacola, were also trained under this contract. Navy H-53 training by HM-12 at NAS Norfolk was added later and has now been completed.
The training program goes beyond the ususal leadership and assertiveness training as developed by various airlines under [47] their cockpit resource management training themes. The curriculum covered aircrew judgment, situational awareness, coping with stress, risk management, workload assessment and time management, the use of checklists and flight planning, and developing communication skills. The goals of the program were to develop a standardized crew coordination training program, run by and for the FRSs, which would be expandable to other aircraft communities.
Squadron flight instructors were initially trained for two weeks at the SimuFlite Training International Division in Dallas. The contractor was required to spend two weeks with each squadron helping the instructors trained at SimuFlite to “stand-up” the training for the remainder of the instructors in the RTS. This was a “turn-key” effort with the contractor, leaving the squadron capable of carrying on its own training at the end of contract in a year’s time. Feedback and evaluation was sought from the squadrons involved to determine the degree of success of the program. To date, the feedback has been favorable.
Some unexpected side efects of the training have been reported by the squadrons that have had their “stand-up.” For the first time in some squadrons, RTS students and instructor pilots are talking to each other and discovering that there is a lack of standardization in their flight instructuion. The instructors who have gone through the course at SimuFlite report that they are better instructors for the training. In addition to being safter pilots, all concerned feel that they will have a smoother, more efficient flight operation due to this traning.
A follow-on contractual effort to expand the program into TACAIR during fiscal year 1989 has begun. The EA-6 and A-6 fleet replacement squadrons at NAS Whidbey Island, Wash., VAQ-129 and VA-128 as well as VA-42 at NAS Oceana, Va., will be receiving the training during the fall of 19888. The S-3 squadrons, VS-40 at North Island, and VS-27 at NAS Cecil Field, Fla., will also be added then. VAW-110 at NAS Miramar, San Diego, Calif., and VAW-120 at NAS Norfolk, flying the E-2C, will be included in the program, as will VAQ-33, flying the A-3B at NAS Key West, Fla. VF-124 at NAS Miramar and VF-101 at NAS Oceana, will represent the F-14 community.
Hopefully, training can be expanded for all multiplaced aircraft RTSs including the P-3, C-130 and the C-9, and for six Naval Air Training Command air wings. The single-seat tactical aviation communities have shown considerable interest in a training program to enhance pilot judgment, situational awareness and communications between cockpits. The project was conceived as a research and development program to prove the ACT concept in reducing pilot-error mishaps. When the materials and methods are perfected for squadron use, the training will be turned over to the Navy’s aviation training commands. In order to maintain effectiveness and take advantage of the latest developments in the field, it will be necessary to continue to train flight instructors as facilitators in conducting these seminars. Also, quality assurance and standardization will have to be maintained.
By whatever name it is called—Aircrew Coordination Training, Cockpit Resource Management or Aeronautical Decision Making Training — this program is an idea whose time has come. All major airlines and the Air Force, Army and Coast Guard have developed and are using such programs. Eventually this training should be made an integral part of initial flight training and all mission-orientated flight instruction in the Navy and Marine Corps.
Note
Dr. Alkov heads the Aviation Safety Programs Branch of the Naval Safety Center’s Aeromedical Division.
[2]
Eighteen years of the CRM wars: A report from headquarters
Daniel E. Maurino
International Civil Aviation Organization (ICAO)
Introduction
Three years ago, Bob Helmreich (1993) delivered to this forum his report on the first 15 years of the CRM wars. Bob then recalled the hardships of the early years; the need to prove beyond anecdotal evidence that CRM was indeed a good idea, and the mounting pressures to implement the evaluation of human factors issues through LOFT (Line Oriented Flight Training). Bob also reviewed the evolution of CRM, from a training method aimed at fixing the individual “wrong stuff” to a systemic approach to safety with a broad perspective well beyond the cockpit door. Last but not least, he defined an agenda for research, including the challenges the international aviation human factors community would come to face over these following three years.
I would like to take up where Bob left off, and update you on the status of the CRM wars. My report will address what arguably are the three major CRM battles in progress:
• the cross-cultural battle;
• the battle for the integration of CRM and technical training; and
• the battle for the evaluation of CRM training.
Bob’s report presented the perspective of a person digging in the trenches and fighting daily for the survival and progress of CRM. The perspective I would like to share with you today is afforded by the strategic view I enjoy from the twenty-fifth floor of the ICAO headquarters building in Montreal. The position upon which my report builds is quite simple and should not be mistaken: CRM is much too valuable a tool to be squandered by misconceptions, incompetence or plain ignorance.
The battle at the intersection of CRM and culture
The one important lesson we learnt while pursuing our Human Factors Programme at ICAO was that human endeavours have a strong cultural component. There are no solutions valid “across the board”, and problems in different contexts...

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