How Essential Is Crew Resource Management To Flight Safety?
Carl Rackman discusses the importance of Crew Resource Management (CRM), and the danger of negative attitudes towards this.
24 Aug 2017
Written by Carl Rackman
Every six months, for every airline pilot, there comes a period of tension; Mandatory flight tests are required for all operational pilots. One is an annual proficiency check to renew your flight crew licence, and the other is a workout and training detail devised by the airline (or operator).
Of the two, I always found the operator check to be the most challenging, but also the most rewarding. It was designed to address the trends of incidents both in the airline and worldwide. Called Line-Oriented Flight Training (LOFT), it provided some very practical and realistic scenarios to cover some of the more obscure incidents and knowledge gaps that were prevalent across a particular fleet.
It was during these LOFT sessions I discovered first-hand the limits of my own abilities, and those of the other crew I trained with. Some of these limits were in the technical knowledge of obscure subsystems, some were in our thinking capacity under pressure, and some were in our limitations as humans.
I was encouraged that our raw flying skills were never shown to be deficient. Once a training detail was completed, we often had some time left to “practice manual flying skills”, which often meant playtime!
Thanks to the high fidelity of modern simulators, I’ve flown the Boeing 777 at street level down the London Mall to Buckingham Palace, under the Golden Gate and Verrazano Narrows bridges and close by other landmarks like the Corcovado in Rio and the Eiffel Tower. On one memorable outing, I landed on the deck of the aircraft carrier USS Constellation in San Diego Harbour! Despite the obvious fun aspect, it leaves you feeling very confident about your ability to fly and handle the aircraft.
Human Or Pilot Error?
Occasionally, there is a high-profile incident or accident where the media blame “pilot error”, a term I absolutely loathe. It’s not just my sense of “family pride” that is challenged, but the blanket assumption that follows; The crew were “bad pilots”.
The term “incompetent” is bandied around, and the crew’s reputation is dragged through the dirt without any sense of compassion for the fact they may be dead, and their loved ones must watch their name being publicly trashed.
I prefer the term “human error”.
Egregious departures from standard procedures and common airmanship have occurred, but whilst not every human error is a pilot error, every pilot error is a human error.
This is why so much airline training has been focused on human performance and limitations. Flying, like surgery, is a complex and hazardous operation that requires high skill levels, combined with sound operating procedures and teamwork, to be successful.
The process of taking an aeroplane from a terminal building parking position, to a different one on the other side of the world is fraught with risk. The art of piloting, if there is one, is to manage and minimise those risks to the point that they no longer threaten the operation. At each step, strong communication is proven to be the key to this process.
The concept of crew resource management (CRM) is relatively new. It was first mooted in the 1970s in response to a sharp spike in aircraft accidents. One of the key problems identified by the pioneers of CRM was the alpha-beta relationship between flight crew.
The experience gap between crew members can be huge. When I first began flying airliners, I had a grand total of 200 flying hours of which just 1.5 were on the Boeing 737 I was about to fly with 140 passengers aboard! My training captain was a grizzled veteran of charter and Far East flying with 20000 hours.
This gradient of knowledge and experience is not unusual. In the past, it could often translate into a steep gradient in perceived authority. The experienced captain often behaved with an autocratic sense of overbearing authority, which other crew members were afraid to challenge, particularly the newly-minted first officer. This “silverback” attitude was a contributing factor in some of the worst flying disasters in history, most notably the Tenerife collision in 1977 which remains the worst civil aviation accident in history, resulting in 583 fatalities.
Aviation was by no means the only industry deficient in this regard. Stories abound from the medical profession of theatre staff looking on silently as a surgeon amputates the wrong limb, even though everyone else in the room recognises the mistake. Accidents as diverse as the Space Shuttle re-entry disaster were found to have human organisational errors at their heart. CRM programmes attempted to address this.
It was a rocky ride to sell CRM to the hardened, highly-competent autocrats of the flight deck fraternity. I remember one story that made the rounds from the early days of CRM training, when it moved decisively from the classroom to the flight simulator.
For many pilots of a certain vintage, it was dismissed as “touchy-feely nonsense”, the preserve of effete, pony-tailed HR managers with bonuses to earn.
One such pilot was undergoing a simulator proficiency check. The session was being monitored by a young manager from the HR department who had to “tick the box” for CRM content. At one point, an engine fire broke out. The captain turned around in his seat to make eye contact with the flight engineer; “John, I love you and I want to have your babies. Now put the ******* fire out!”
Captain Al Haynes
Such was the state of play by the late 80s. Then something happened that changed the perception of CRM forever.
On a beautiful July day in 1989, United Airlines flight 232 took off from Denver’s old Stapleton airport enroute to Chicago O’Hare. It was a short hop for the widebody DC-10 with 296 passengers and crew aboard.
Captain Al Haynes was a veteran pilot with 30,000 flying hours, of which 7000 were on the DC-10. The first officer and flight engineer were also experienced crew, and the flight also carried a route check captain.
Barely an hour into the flight, the tail-mounted third engine suffered a catastrophic failure which sent parts of the compressor flying through the upper airframe, severing all three hydraulic system lines and causing an almost complete loss of hydraulic pressure. The flight control surfaces and third engine throttle were jammed in place, trapping the aircraft in a gradual right turn.
Upon hearing the extent of the damage, the United Airlines control center alerted its management team that the incident was non-survivable, and would result in the catastrophic loss of the aircraft and all occupants.
But Al Haynes and his crew worked the problem, talking through the system failures and exploring solutions. They worked together as a team, asking relevant questions and assigning tasks to specific people.
For the next 44 minutes, they battled the odds to nurse their crippled aircraft to a runway approach at Sioux City using only the left and right throttles to control the flightpath.
The aircraft crashed on landing, but the crew were among the survivors (over half the occupants survived) and were universally praised for their handling of what should have been a complete loss.
Once the details of the investigation began to circulate, particularly the CVR recording, pilots and trainers around the world began to perk up. Al Haynes himself would say of his CRM training:
“But the preparation that paid off for the crew was something that United started in 1980 called Cockpit Resource Management…All the other airlines are now using it. 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 practiced, 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.”
Suddenly CRM was not an additional luxury. It was the essential difference between success and failure. Airlines scrambled to implement practical and workable CRM training to follow United’s example.
United Airlines was at that time the world leader in CRM training. They had made the step of taking it seriously following the loss of a DC-8 near Portland, Oregon in 1978. It ran out of fuel as the crew discussed a possible landing gear problem which turned out to be a faulty microswitch.
In the thirty years since Sioux City, CRM training has evolved to the point where the airline industry leads the world in this kind of creative thinking about how professionals communicate in complex technical environments.
Airline CRM professionals are a recognised part of the training industry, offering consultancy with the oil and chemical industry, medical profession and other critical technical roles.
On my last simulator check, two trainers from the nuclear power industry were sitting in the back of the simulator as observers. They watched us dealing with a LOFT exercise that involved a seized engine compressor, and a diversion from the Atlantic Track System into Reykjavik during snowy conditions. We applied all the sound measures of timekeeping, fuel management, diversion management, communication with crew, passengers and ground controllers, airline control centre and passenger services. We used as many resources as we could, including auto flight systems, flight management computers, VHF and HF radio, ACARS and sat phone communication, crew members, and of course, splitting the workload between us to ensure that the aircraft remained under control. We used mnemonics to help us manage the problem (DODAR and Plane, Path People), and by the time we landed successfully, my throat was dry, not from tension, but from talking.
After our debriefing, we had a Q&A session with the nuclear engineers, as they were seeking to apply some of the same principles to their own human factors training. The first thing that either said after the debriefing was that they were amazed there was so much communication.
Their main takeaway from watching pilots work a complex problem was that you had to communicate effectively.
The 21st Century airline pilot is an information manager. The electronic wizardry that captures the imagination of the public, is like the refinements one finds on modern cars; Power steering, satnav and head-up displays all have their analogues in the modern flight deck, but like a driver (self-driving cars notwithstanding!), the pilot still has to fly. In addition, they must think and process to a degree that was unimaginable thirty or forty years ago.
It’s not enough to be the strong silent leader anymore. One of the command skills I was taught was that if the flight deck goes quiet during problem-solving, check your crewmate. It’s usually a sign of overload or confusion.
The art of asking open questions, checking workload assignments and being ready to question and review decisions you’ve made, are at the heart of CRM.
That said, CRM is not a solution to the human error problem, it simply introduces specific training in avoiding and mitigating it.
Recent studies suggest that the positive effects of traditional CRM training may have plateaued, and in fact there is a rising trend in CRM-related incidents. There remain many human reactions, personality traits and good old fashioned mistakes that defy even good CRM.
If we are honest, there are still some pilots who remain impervious to it. It has often been said in training that the people most likely to benefit from implementing CRM, are the ones least likely to perceive any benefit.
Sadly, these attitudes are often found out only in the crucible of real-life tragedy.
CRM is not so much touchy-feely anymore. It’s more lifey-deathy.
Notable Incidents Where Crew Communication Or Problem-Solving Management Was A Significant Factor
Source: Aviation Safety Database
• Antillean Airlines 980, ditched in the sea off the Virgin Islands 2 May 1970. 23 fatalities, 40 survivors
• Pan Am/KLM disaster, Tenerife Los Rodeos 27 March 1977. 583 fatalities, 61 survivors
• United Airlines 173, crashed near Portland, Oregon 28 December 1978. 10 fatalities, 179 survivors
• Eastern Airlines 401, crashed in Florida Everglades 29 December 1979. 101 fatalities, 75 survivors
• Saudia 163, fire after successful emergency landing at Riyadh 19 August 1980. 301 fatalities, no survivors
• British Midland 92, crashed near East Midlands Airport, UK 8 January 1989. 47 fatalities, 79 survivors
• United Airlines 232, crashed at Sioux City, Iowa 19 July 1989. 111 fatalities, 185 survivors