This will always be a work in progress
First: a confession. I seem to write a new article about CRM every two years and the previous edition of this website had four of them. Second: It isn't my fault. The path of CRM (from Cockpit Resource Management of the past to Crew Resource Management) of the present) isn't a straight line. Third: It is only getting worse. Other professions are co-opting CRM and promise to confuse things further.
So that is why this page always seems to be under revision.
Photo: Struggle for control, from "The High and the Mighty"
What follows is my latest attempt to bring sanity to the subject. Wish me luck.
Photo: Pan American Airways Boeing 314 "Yankee Clipper," 1939, (Library of Congress)
Click photo for a larger image
The following narrative is from the excellent book, Skygods, by Robert Gandt. It may be one of the best books on Crew Resource Management ever written. Of course it is thought more of a history of the airline than anything else. But the very concept of aircraft pilots in crew aircraft comes from the days Pan American Airways flew the majestic flying boats, just a few decades after the birth of powered flight itself.
[Gandt, p. 19]
Back in the boat days . . .
The new hires heard a lot of that during their training. Whenever someone talked about an event that happened in the first half of Pan Am's existence, his voice took a reverential tone: "Things were different in the boat days, you know. Back in the boat days we used to ... "
Everything of consequence happened then. Those were the days when Pan American took to the skies, and oceans, in its great flying boats-lumbering, deep-hulled leviathans that took off and alighted on water. To the old-timers, everything that happened after the boat days was anticlimactic. Then came the coldly efficient, unromantic land planes like the Douglas DC-4 and DC-6 and the Boeing Stratocruiser and then the antiseptic, kerosene-belching jets.
The flying boat was a hybrid-neither fish nor fowl-born of the notion that because two-thirds of the planet happened to be covered with water, it made sense to use the stuff for taking off and landing airplanes. And for a while that was the only option. Conventional land planes required long runways of thick concrete in order to take off with a heavy load. Until the late thirties, no such hard-surfaced runways existed anywhere in the world. Only the flying boat, using miles of sheltered harbor and lagoon, was able to lift the vast store of fuel required to carry a payload across an ocean.
There was also a psychological factor. Passengers took comfort in the knowledge that should calamity strike and the flying boat be no longer able to fly, it could become, in fact, a boat.
Juan Trippe, it was said, had a nautical fetish. On the walls of his home hung paintings of clipper ships, the fast full-rigged merchant vessels of the nineteenth century. It was Trippe's dream that his airline, Pan American, would become America's airborne maritime service. Pan Am flying boats would be the clipper ships of the twentieth century.
So he called his flying boats Clippers. Aircraft speed was measured in knots. The pilots who commanded the clippers were given the rank of captain. Copilots became first officers.
It wouldn't do for a Pan American pilot to look like the scruffy, leather-jacketed, silk-scarved airmail haulers of the domestic airlines. Instead, they wore naval-style double-breasted uniforms with officer's caps. When they boarded their flying boats, they marched up the ramp, two abreast, led, of course, by the captain.
Trippe understood pilots, having been one himself. He knew they were prima donnas who loved the pomp and perquisites of command. The captains of the great oceangoing, four-motored behemoths like the China Clipper needed a suitable grand title. So he gave them one: Master of Ocean Flying Boats.
Like commanders of ships at sea, the Masters of Ocean Flying Boats were a law unto themselves. While under way they exercised absolute authority over their aircraft and all its occupants. And with such authority went, inevitably, arrogance.
Juan Trippe was a visionary in many ways; he foresaw profitable international airline service before anyone else thought it even possible. He pushed aircraft manufacturers into bigger, faster, longer. You can argue that he was the driving force behind the Boeing 707 and 747 programs. Pan American World Airways and the Boeing 707 have a linked history, and that history shows just how important Crew Resource Management is in an airplane with more than one pilot.
Photo: The first three Pan Am Boeing 707s (N709PA, N710PA, N711PA), Seattle, Washington, 1958, (Public Domain)
Click photo for a larger image
During its lifespan, nobody crashed more Boeing 707s than Pan American World Airways. In fact, the accident rate in their first real transoceanic jet was going up while the rate for the rest of the industry was going down. There are lessons here.
Note: this list does not include aircraft involved with hijackings (24 Nov 1968, 22 Jun 1970, 29 May 1971, 17 Dec 1973).
By the close of 1973, Pan American World Airways had lost ten Boeing 707s, not including one lost in a hijacking. (The 3 Feb 1959 aircraft was repaired and returned to service.) As Robert Gandt put it, "Pan Am was littering the islands of the Pacific with the hulks of Boeing jetliners." Pan Am initiated a study to figure out what was wrong.
As the study was being conducted, Pan Am crashed two more.
After the crash of Pan 812 the FAA had had enough. The corrective action was necessarily severe. Pan American World Airways fully embraced the fixes and it is telling that for the remainder of their existence, they had a stellar safety record. The demise of the airline, I think, had more to do with their bet on larger and larger aircraft when fuel economy was becoming the driving force in the industry. Lockerbie and Tenerife sealed their fate. (Neither incident was due to Pan Am or its pilots.)
[Gandt, p. 115]
The Bali calamity brought Pan Am's 707 losses to eleven. Pan Am had crashed more Boeing jets than any other carrier in the world. And not just 707s. A three-engine 727 was lost during a night approach to Berlin. One of the new 747s struck the approach lights and incurred heavy damage during a miscalculated takeoff in San Francisco. Another 747 was lost to a new and still unrecognized threat. Terrorists hijacked the jumbo jet in Amsterdam, then had it flown to Cairo where they blew it up.
Something had to be done. Before the smoke subsided from the burning wreckage on Mount Patas in Bali, the probe of Pan American's flight operations had begun.
Inspectors from the Federal Aviation Administration climbed aboard Pan Am Clippers all over the world. FAA men rode in cockpits, pored through maintenance records, asked questions, observed check rides and training flights.
The inspection went on for six weeks. The FAA's findings confirmed the dismal facts that the internal Operations Review Group had already determined: Pan Am was crashing airplanes at three times the average rate of the United States airlines. Worse, Pan Am's accident rate was on the rise, a reverse of the steadily decreasing industry-wide accident experience with jet airliners.
The report was scathing. Pan Am's accidents in the Pacific, declared the FAA, involved "substandard airmen." Training was inadequate, and there was a lack of standardization among crews. The FAA's list went on to cover a host of operational items, matters of training manuals, route qualification, radio communications, and availability of spare parts.
But at the heart of Pan Am's troubles, according to the FAA, were human factors. That was the trendy new term psychologists were using in accident reports. It meant people who screwed up. When applied to airline cockpits, it had the same taint as pilot error.
With the exception of a crash caused by a cargo fire, and excluding the unknown circumstances of the Tahiti crash, every recent Pan Am accident could be attributed to some form of pilot error.
The indictment landed in Skygod country like a canister of tear gas.
Substandard airmen? Wait a minute, you bureaucratic piss ants . .. this is Pan American, the world's most experienced airline. . . we were the first to fly jets, the first to . . .
That was then, said the Feds. This is now. Clean up your act, or you will be the world's most grounded airline.
Heads, of course, would have to roll. And so they did, particularly in the San Francisco base, where the Skygod umbrella had long ago been raised over the heads of the venerable Masters of Ocean Flying Boats.
[Gandt, pp. 117-119]
But the most profound change was still coming. It was an invisible transformation and it had more to do with philosophy than with procedure. Pan Am was forced to peer into its own soul and answer previously unasked questions. Instead of What's wrong with the way we fly airplanes? the question became What's wrong with the way we manage our cockpits?
A new term was coming into play: crew concept. The idea was that crews were supposed to function as management teams, not autocracies with a supreme captain and two or three minions. It meant the captain was still the captain, but he no longer had the divine license to crash his airplane without the consent of his crew. Copilots and flight engineers-lowly new hires-were now empowered to speak up. Their opinions actually counted for something.
Disagree? With the captain? In the sanctums of the Skygods, it amounted to anarchy. Hadn't the Masters of Ocean Flying Boats labored for thirty years to preserve the cult of the Skygod? The barbarians were storming the gates.
But history was running against the ancient Skygods. Though Pan American technology had led the world into the jet age, Pan Am's cockpits had not emerged from the flying boat days. A new era, like it or not, was upon them. The Skygods were about to become as extinct as pterodactyls.
The cockpit transformation came down to two separate problems. The first was to de-autocratize the cockpit-to dismantle the Skygod ethic. Pan Am captains must master the subtle distinction between commanding and managing. Junior pilots must learn to participate in the decision-making process.
This was revolutionary. Pan Am copilots actually having an opinion . . .
The other problem was standardization. There wasn't any. Pilots from the unregulated, make-the-rules-as-you-go-along flying boat days were inherently nonstandard. They were, by God, supposed to be different. Flying was a game for individuals-chest-thumping, throttle pushing, flint-eyed Masters of-Ocean-Flying Boats-not compliant drones.
The newer breed of airmen had come from a different environment. High-tech airplanes demanded a collaborative effort from their crews. Uniqueness in a pilot was okay, but it ought to be manifested by excellence, by a mastery of technical skill, rather than by eccentricity.
The magic word standardization brought eventual relief. It meant that everybody operated the airplane the same way. Total strangers captains, first officers, flight engineers-could check in for a flight, enter the cockpit, and work in total harmony. They could fly the airplane around the world-and each would know what the other would do. Gone were the surprises.
It would take time to change an ethic so deeply embedded in the airline's skin, but there was no choice. It had to work.
And it did. The nightmare was over. From 1974, following the Bali crash, not another Pan Am 707 was lost in a crash.
The 747, which was emerging as the new flagship, established itself as the safest airliner ever operated by Pan Am. Not a single life would ever be lost in a flying accident with a Pan Am 747*.
Pan American went on to establish a safety record that was the envy of the industry.
* In neither of two fatal 747 disasters-the bombing of PA 103 in 1988 and the runway collision with a KLM 747 at Tenerife in 1977-was the 747 or the Pan Am crew held to blame.
Right about the time of Pan Am's conversion to the "crew concept," other airlines were having their own problems and it became apparent that even when crews got along, something more was needed. The focus, at least the pereived focus, was on the captain.
Figure: Eastern Airlines 401, from anonymous (GNU Free Documentation License)
[Cortés, Cusick, pp. 128-129]
For more about this accident, see: Eastern Air Lines 401.
For more about this accident, see: United Airlines 173.
[Crew Resource Management (Kanki, Helmreich, Anca), §1.4.4] A 1979 NASA study placed 18 airline crews in a Boeing 747 simulator to experience multiple emergencies. The study showed a remarkable amount of variability in the effectiveness with which crews handled the situation. Some crews managed the problems very well, while others committed a large number of operationally serious errors. The primary conclusion drawn from the study was that most problems and errors were introduced by breakdowns in crew coordination rather than by deficits in technical knowledge or skills. The findings were clear: crews who communicated more overall tended to perform better and, in particular, those who exchanged more information about flight status committed fewer errors in the handling of engines and hydraulic and fuel systems and the reading and setting of instruments.
Captains became kinder and gentler, at least comparatively so. First officer still needed a little encouragement to speak up. This was generation two.
Figure: Air Florida 90, from AirDisaster.com.
[Cortés, Cusick, pp. 129-130]
For more about this accident, see: Air Florida 90.
For more about this accident, see: United Airlines 232.
The United States military and most commercial airline businesses embraced Cockpit Resource Management early and the improvements were dramatic. As more and more of the world embraced CRM, the accident rates fell accordingly. One need only examine the hold outs to fully understand just how far we've come. Examine Korean Airlines for a thirty-seven year look at a country's airlines ignoring the call for CRM, being forced into it, and then working their way around it. It isn't an Asian culture thing. The Japanese realized early on that crashing airplanes and killing passengers was a bad business model.
Guess what? There is more to the crew than just the cockpit. In the third attempt, "cockpit" becomes "crew." Okay, that's good. But the academicians start to realize there is an entire new field of study they can corrupt, and things start to go downhill.
Photo: Army medicine, from Jim Bryant, NW Guardian, (Creative Commons.)
[Cortés, Cusick, p. 131]
[Crew Resource Management (Kanki, Helmreich, Anca), §6.1] The term non-technical skills (NTS) is used by a range of technical professions (e.g. geoscientists) to describe what they sometimes refer to as "soft" skills. In aviation, the term was first used by the European Joint Aviation Authorities (JAA) to refer to CRM skills and was defined as "the cognitive and social skills, of flight crewmembers in the cockpit, not directly related to aircraft control, systems management, and standard operating procedures." They complement workers' technical skills and should reduce errors, increase the capture of errors and help to mitigate when an operational problem occurs.
[Crew Resource Management (Kanki, Helmreich, Anca), §6.2] As concern about the rates of adverse events to patients by medical error grew, medical professionals began to look at safety management techniques used in industry. One technique that has attracted their interest is the training and assessment of non-technical skills.
Much of the rest of the world, especially that which deals with life and death issues, adopted CRM (or NTS) and have had to do the hard sell to obtain "buy in" from their professionals. Doctors, for example, may reacted just as early airline captains did thirty to forty years ago. Meanwhile, we in the aviation world have seen decades of progress and it is a rare crewmember these days who attempts to push back.
You can recognize the generations of CRM that followed because they tended to involve non-aviation aspects of getting along and often had some kind of other terminolgy to help confuse things. Around this time I started to lose interest in CRM because it ceased to serve more to confuse than clarify.
[Cortés, Cusick, pp. 131-132]
. . . is that we in aviation are training crews as if we've made zero progress in the last thirty-plus years. Take a look at the 1990 FAA text and notice there is very little change from what came before and after. They are still teaching this.
Figure: US/Canadian Operators Accident Rates by Year to 1990, from CRM Handbook, figure 1.
[Crew Resource Management: An Introductory Handbook, pg. 1] From the 1950s to the 1990s we have witnessed a steady decline in aviation accidents. This decline in aviation accidents has been attributed to better equipment, better training, and better operating procedures.
More about this: Accident Rates.
Notice the chart looks pretty flat from 1986 on.
Figure: Changes in accident causal factors over time, from CRM Handbook, figure 2.
[Crew Resource Management: An Introductory Handbook, pg. 1] As Figure 2 illustrates, as accidents related to equipment weaknesses have decreased, accidents attributed to human weaknesses have increased.
That is what the chart suggests, but it is a lie.
[Crew Resource Management: An Introductory Handbook,pg. 2] Figure 1 and Figure 2 suggests two points. First, Figure 1 indicates that after a sharp drop in the 1960s, accident rates have leveled off from 1970 through 1990. Second, the trends in causes of accidents illustrated in Figure 2 show that human error has remained a major contributing factor in aviation accidents during these latter years.
Figure: US/Canadian Operators Accident Rates by Year 1993 to 2012, from Boeing Statistical Summary.
The first chart seems to show the accident rate has leveled off and we aren't getting any better. This is a distortion caused by the constant scale of the left axis. It is hard to see a trend when the changes are small relative to the scale. If you zoom in you will see the trend continues, as shown by the updated chart here.
The second chart is a lie of improperly used statistics. The chart clearly says "Relative proportion of accidents cause." In plain English:
So why is overplaying the problem a problem when it comes to training? Because the problem has changed. The problem in aviation used to be a culture that gave the captain complete authority and discouraged any kind of resistance to that authority. We are over that. While it may be true that not every pilot fully embraces CRM, the vast majority of them say they do. That word, "say," is important here. Because the new problem is that we have a culture that expects all flight crews to embrace CRM and that we have some pilots that may not know how to do that, or are doing that in thoughts only. We have a new problem:
Notice there is a common factor to all these problems. That leads us to a new training paradigm . . .
Do you get the idea I liked CRM through the third generation and lost faith in it after that? The CRM fundamentals taught during initial courses are sound and should be understood before moving on to training. Much of what follows comes from the references given below, most mostly these are my thoughts. I've learned CRM from the worst examples as well as the best, so perhaps my experiences will save you the trouble of learning things the hard way. Comments, as usual, are welcome, just hit the contact button above.
Photo: Captain Clarence Over, from the movie "Airplane."
Photo: Captain Clarence Over, First Officer Roger Murdock, and Second Officer Victor Vostock, from the movie "Airplane."
I spent a fair amount of time on dysfunctional cockpit crews. I also got a jumpseat view of a few more as an instructor and examiner pilot. But I've been fortunate in that for most of my career, most of the crews I've flown with seemed to have "gotten it." The "it" was how to work together as a team before, during, and after moments when things didn't go as planned. So here are the traits I've notice on all successful crews.
Many books on the subject will talk about a process, from start to finish, when making decisions. In aviation, where time is a factor, it may be helpful to think of decision-making in the form of a cycle. The following steps are repeated as necessary and as time permits.
In a healthy CRM environment, questions are encouraged and answered openly and nondefensively.
[CRM Leadership & Followership 2.0, Antonio Cortés] Show Respect for Fellow Crewmembers. Showing respect to the other members of the crew, naturally including the captain, is not just a matter of courtesy, it is fundamental to fostering a sense of shared purpose that is the building block for teamwork. One of the most important ways of showing respect is by listening to others. This means actively listening for content in what another crewmember is saying, not just "hearing" what is being said.
In a healthy CRM environment, crewmembers are encouraged to speak up and state opinions with appropriate persistence until there is a clear resolution. This can be encouraged by captains who ask the right questions. "Do you have anything to add?" prompts a yes/no answer and a "no" can appear to the timid crewmember to be a threat to the captain's authority. "What am I forgetting?" will be seen as a request for help and encourages input.
In a healthy CRM environment, crewmembers are allowed to question the actions and decisions of others and to seek help from others when necessary. Of course, the final arbiter is the captain, who must weigh all concerns before deciding. An important point is that the captain must err on the side of safety, so that a crewmember’s concern that may or may not be valid, in the captain’s view, may carry the day if the action lowers potential risk.
[CRM Leadership & Followership 2.0, Antonio Cortés] Regardless of what tone has been set by the captain, crewmembers have an obligation to be assertive and to voice concerns and opinions on matters of importance to the safety of the flight.
Crewmembers must understand that there are few things more corrosive to a crew’s integrity than to have a crewmember disagree with the captain in front of the rest of the crew or passengers. A good way to show respect for good crew resource management is to disagree with other crewmembers (including the captain) in private, if time permits.
If the captain is not listening or doesn’t grasp the gravity of a situation, the following techniques may prove useful:
It is all too tempting to take a look at the Pan American World Airways Boeing 707 era and say, "that's ancient history." It predates the 1979 NASA study which is supposed to have given birth the Crew Resource Management (CRM), after all! But here we are, almost forty years later, and we can still see old vestiges of the those crusty old Pan Am Captains — the ones the CEO called "Master of Ocean Flying Boats" — in cockpits today, as well as the occasional first officer too afraid to speak up.
So there are lessons aplenty. First, lessons on how to avoid falling into the culture that gave rise to these problems in the first place. And, secondly, lessons on how to fix those who have somehow become broken.
Of course these are just my thoughts. Am I wrong? Or can these be improved upon? Hit the "contact" button on the bottom or top if this page, and let me know.
We in aviation are not alone with these Masters of Flying Boats. Perhaps the best way to learn how to spot one is to examine one in another profession. Here's a report from Surgeon Atul Gawande:
[Gawande, p. 103] The most common obstacle to effective teams, it turns out, is not the occasional fire-breathing, scalpel-flinging, terror-inducing surgeon, though some do exist. (One favorite example: Several years ago, when I was in training, a senior surgeon grew incensed with one of my fellow residents for questioning the operative plan and commanded him to leave the table and stand in the corner until he was sorry. When he refused, the surgeon threw him out of the room and tried to get him suspended for insubordination.) No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. "That's not my problem" is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time.
Advisory Circular 120-51E, Crew Resource Management Training, 1/22/04, U.S. Department of Transportation
Aircraft Accident Report 4/90, Department of Transport, Air Accidents Investigation Branch, Royal Aerospace Establishment, Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989
Boeing Commercial Airplanes, Statistical Summary of Commercial Jet Airplane Accidents, Worldwide Operations 1959 - 2012, 2013
Cortés, Antonio; Cusick, Stephen; Rodrigues, Clarence, Commercial Aviation Safety, McGraw Hill Education, New York, NY, 2017.
Cortés, Antonio, CRM Leadership & Followership 2.0, ERAU Department of Aeronautical Science, 2008
Crew Resource Management: An Introductory Handbook, DOT/FAA/RD-92/26, DOT-VNTSC-FAA-92-8, Research and Development Service, Washington, DC, August 1992
Dekker, Sidney and Lundström, Johan, From Threat and Error Management (TEM) to Resilience, Journal of Human Factors and Aerospace Safety, May 2007
Fallucco, Sal J., Aircraft Command Techniques, 2002, Ashgate, Farnham, England
Flight Safety Foundation, Aviation Safety World, "Pressing the Approach," December 2006
Gann, Ernest K., Fate is the Hunter: A Pilot's Memoir, 1961, Simon & Schuster, New York
Gandt, Robert, Skygods: The Fall of Pan Am, 2012, Wm. Morrow Company, Inc., New York
Gawande, Atul., The Checklist Manifesto: How to Get Things Right, 2009, Metropolitan Boos, Henry Holt and Company, LLC, New York.
Helmreich, Robert L., Klinect, James R., Wilhem, John A., Models of Threat, Error, and CRM in Flight Operations, University of Texas
Kanki, Barbara; Helmreich, Robert; and Anca, José, Crew Resource Management, Academic Press, Amsterdam, 2010.
Lutat, Christopher J. and Swah, S. Ryan, Automation Airmanship, McGraw Hill Education, London, 2013.
Portugal Accident Investigation Final Report, All Engines-out Landing Due to Fuel Exhaustion, Air Transat, Airbus A330-243 marks C-GITS, Lajes, Azores, Portugal, 24 August 2001
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