Introduction to Crew Resource Management - by Ahmed Haouaria

12 Jan 2018
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Crew Resource Management (CRM) is the application of human factors knowledge and skills to the efficient and safe flight operations with the objective of properly using all available resources (equipment, systems and people). CRM combines individual skills and human factors knowledge with effective crew coordination.

Commercial air transport remains one of the safest means of transportation of people and goods from one point to another. The number of fatal incidents per mile travelled is extraordinarily low compared to other means of transport.  However the industry suffers a paradox of very low accident rate but a very high potential for loss of life when an accident does occur.

Humans, by their very nature, make mistakes; therefore, it should come as no surprise that human error has been implicated in a variety of occupational accidents, including 70% to 80% of those in civil and military aviation


 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 essential reason for the existence of air Airline 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, engineers  and dispatchers) through goal setting, teamwork, awareness and both pro- and reactive feedback (Helmreich).

The training of Crew Resource Management for commercial aircrew has become a mandatory practise under the majority of the world aviation regulatory environments (CAA, FAA, JAR, EASA) and practice of Crew Resource Management is an integral part of commercial airline training and operations.

.CRM as a response to new insights into the causes of aircraft accidents

CRM was developed as a response to new insights into the causes of aircraft accidents which followed from the introduction of flight data recorders (FDRs) and cockpit voice recorders (CVRs) into modern jet aircraft. Information gathered from these devices has suggested that many accidents do not result from a technical malfunction of the aircraft or its systems, nor from a failure of aircraft handling skills or a lack of technical knowledge on the part of the crew; it appears instead that they are caused by the inability of crews to respond appropriately to the situation in which they find themselves. For example, inadequate communications between crew members and other parties could lead to a loss of situational awareness, a breakdown in teamwork in the aircraft, and, ultimately, to a wrong decision or series of decisions which result in a serious incident or a fatal accident.

Crew resource management is a model of management used to manage threat and error in aviation.

The core elements of CRM

  • the goal of a safe flight
  • cooperation and communication between pilots, ATC, cabin crew and dispatch,
  • monitoring of internal (intra-crew and aircraft) and external situation for threats (e.g. poor teamwork, weather, terrain, fuel state, location of aircraft in regards to flight plan) and
  • feedback to enable practices to be adjusted and threats to be evaluated

These core elements allow throughputs to be created which enhance system performance.

  • Awareness of the current state of both internal (on-board 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),

By using the core elements and throughputs of goals, teamwork (communication/cooperation), situational awareness and feedback the crew practice threat detection and error avoidance behaviours.

Example application of the crew resource management model

HELIOS 522

Date: 14 August 2005

 ‘’May Day: Ghost Plane”

Overview

  • On August 15, 2005, about 12:04 p.m. Helios flight 522, a Boeing 737-300 impacted into the ground in Athens nearly 3 hours after its departure from Cyprus;
  • The previous crew had reported an issue with the pressurization system which required a maintenance check. After the maintenance procedure the engineer failed to put the switch to the correct AUTO position;
  • The flight crew failed to identify and rectify the position of the switch from the MANUAL to AUTO in three different occasions during the preliminary checks and subsequent checklist;
  • As the aircraft climbed, the pressure inside the cabin gradually decreased, the warning was misunderstood by the effect of HYPOXIA and appropriate actions were not taken, the oxygen masks deployed automatically in the cabin without further communication within the cabin-cockpit crew;
  • Two Air Force aircraft were sent after no communication with the ATC and reported the FO unconscious and a 3rd person in the cockpit with a mask on (Flight attendant);
  • The aircraft flown by the Auto-pilot entered a holding pattern and after fuel exhaustion and engines flame-out collided into the ground. The airplane was destroyed by impact forces. No survivors.

Facts

  • Crew current & qualified;
  • No behavioural or medical condition that  can adversely affect  the crew’s performance;
  • No evidence of crew fatigue;
  • Aircraft serviceable;
  • Time: Day flight / Weather Good;
  • Flight Route Cyprus to Athens.

Flight Crew

  • Captain
    • 59
    • TT 17000 hours
    • No accident / incident
    • Presented typical “Command” attitude problem in communication skills
  • First Officer
    • 51
    • TT 7500 hours
    • No accident / incident
    • Presented concerns about captain’s attitude
    • Difficulty with complex tasks, checklist discipline and SOP’s procedures

Threats

  • Checklists not followed;
  • Engineer not completing procedures;
  • Cockpit preparation not done;
  • Cabin crew not communicating after mask deployment;

Unable to identify HYPOXIA signs and symptoms

 

Hellenic Air Accident Investigation and Aviation Safety Board

  • Flight crewmembers’ failure to use available cues and aids to identify the airplane’s warnings;
  •  Incapacitation of the crew due to hypoxia;
  • Eventual fuel starvation;
  • Impact with the ground.

How may this accident been prevented?

  • Confirming maintenance procedure completed;
  • Cross Check cockpit preparation;
  • Complete check lists appropriately;
  • Improve master warning identification;
  • Cabin crew procedures, communicate with cockpit after mask deployment;
  • Identify signs of hypoxia and don QDM.

Conclusion

  • Threats & Errors leading to Loss of Situational Awareness and subsequent adverse effect on Safety of Flight.

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