Making Air Travel Safer Through Crew Resource Management
Crew Resource Management has prevented accidents and saved lives in the aviation industry — and may save lives in hospital operating and emergency rooms.
In the 1970s, investigators discovered that more than 70 percent of air crashes involved human error rather than failures of equipment or weather. A NASA workshop examining the role of human error in air crashes found that the majority of crew errors consisted of failures in leadership, team coordination and decision-making.
The aviation community responded by turning to psychologists such as John K. Lauber, PhD, and Robert Helmreich, PhD, to develop new kinds of psychological training for flight crews. That training focuses on group dynamics, leadership, interpersonal communications and decision-making. The training is known as Crew Resource Management (CRM). Lauber, a former member of the National Transportation Safety Board, defined CRM as "using all available sources — information, equipment and people — to achieve safe and efficient flight operations." More specifically, CRM is the process used by crew members to identify existing and potential threats and to develop, communicate and implement plans and actions to avoid or mitigate perceived threats. Using CRM methods, airplane crews can avoid, manage and mitigate human errors. And as secondary benefits, CRM programs improve morale and enhance efficiency of operations.
As part of the validation of the behavioral impact of CRM training, Helmreich (who is now deceased) and colleagues at the University of Texas Human Factors Research Project developed an observational process, the Line Operations Safety Audit (LOSA) to assess CRM practices. In LOSA, expert observers ride in the cockpit on scheduled flights under conditions of strict confidentiality and record not only CRM practices but also threats in the operational environment and how they are managed, as well as the nature and management of crew errors. LOSA data have provided valuable information about the threats that air crew members face, and how CRM practices help them deal with those threats.
CRM alerted the aviation industry to the human interactions that are an integral part of any team performance. This training has the potential to save lives and money, as well as prevent accidents and lawsuits.
While no one can assess how many lives have been saved or crashes averted as a result of CRM training, the impact has been significant. LOSA data demonstrate that 98 percent of all flights face one or more threats, with an average of four threats per flight. Errors have also been observed on 82 percent of all flights with an average of 2.8 per flight. Consistent with the outstanding safety record of commercial aviation, the great majority of errors are well managed and inconsequential, due in large measure to effective CRM practices by crews. LOSA provides organizations and regulators with a valid means of monitoring normal operations. By understanding what crews do successfully as well as where things go wrong, researchers can help develop more effective training and safety initiatives.
A real-world example of how CRM may have saved lives can be found in the textbook Social Psychology, by psychologist David Myers, PhD, comparing two airline crashes in the 1980s:
Helmrich (1997)...notes that flawed group dynamics were evident when an Air Florida plane lifted off from Washington's National Airport (now Reagan National Airport) on a winter day in 1982. Ice in a sensor caused the speed indicators to read too high, leading the captain to apply too little power as the plane ascended:
First Officer: Ah, that's not right.
Captain: Yes, it is, there's 80 [referring to speed].
First Officer: Nah, I don't think it's right. Ah, maybe it is.
Captain: Hundred and twenty.
First Officer: I don't know.
It wasn't right, and the first officer's muting his concerns led to the plane's stalling and crashing into a Potomac River bridge, killing all but five people on board.
But in 1989, the three-person crew flying a United Airlines DC-10 flight from Denver to Chicago responded as a model team to imminent disaster. The crew, whose members had been trained in crew resource management, faced the disintegration of the center engine, severing lines to the rudder and ailerons needed to maneuver the plane. In the 34 minutes before crash landing just short of the Sioux City airport runway, the crew had to devise a strategy for bringing the plane under control, assessing damage, choosing a landing site, and preparing the crew and passengers for the crash. Minute-by-minute analysis of the cockpit conversation revealed intense interaction — 31 communications per minute (one per second at its peak). In these minutes, the crew members recruited a fourth pilot who was flying as a passenger, prioritized their work, and kept one another aware of unfolding events and decisions. Junior crew members freely suggested alternatives and the captain responded with appropriate commands. Bursts of social conversation provided emotional support, enabling the crew to cope with the extreme stress, and to save the lives of 185 of the 296 people on board.
Based on the evidence that CRM is effective, the International Civil Aviation Organization, a regulatory component of the United Nations, began requiring CRM programs for member countries. CRM also informed the development of maintenance resource management, an effort to improve teamwork among aircraft maintenance workers. The U.S. Air Force, among others, now uses MRM training programs to boost communication, effectiveness and safety among the crews that maintain and repair aircraft.
The medical community is also responding to findings of human error and failures by adapting aviation's approach to crew coordination. The U.S. Department of Health and Human Services has developed a program called TeamSTEPPS to improve communication and teamwork skills among health care professionals, with the goal of improving patient health and safety. The program is being implemented nationwide via six medical schools that serve as regional training centers. Conceptually, TeamSTEPPS parallels CRM and crisis management.
CRM training is also being used in air traffic control, firefighting and industrial settings, including offshore oil operations and nuclear power plants. The training helps workers in control rooms and emergency command centers avoid making operational errors that may lead to accidents.
Agency for Healthcare Research and Quality: TeamSTEPPS (2014). Retrieved February 14, 2014 from http://teamstepps.ahrq.gov/
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). Moffett Field, CA: NASA-Ames Research Center.
Flin, R. H. (1997). Crew resource management for teams in the offshore oil industry. Team Performance Management, 3( 2), 121-129.
Helmreich, R.L. (2004). Managing threat and error to increase safety in medicine. In R. Dietrich & K. Jochum (Eds.), Teaming Up. Components of Safety under High Risk. Aldershot, UK: Ashgate.
Helmreich, R. L., & Davies, J. M. (1996). Human factors in the operating room: Interpersonal determinants of safety, efficiency and morale. In A.A. Aitkenhead (Ed.), Bailliere's Clinical Anaesthesiology: Safety and Risk Management in Anaesthesia, 277-296. London: Bailliere Tindall.
Helmreich, R. L., & Foushee, H. C. (1993). Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In E. Weiner, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management, 3-45. San Diego, CA: Academic Press.
Helmreich, R.L., Klinect, J.R., Wilhelm, J.A., Tesmer, B., Gunther, D., Thomas, R., Romeo, C., Sumwalt, R., & Maurino, D. (2002). Line Operations Safety Audit (LOSA). DOC 9803-AN/761. Montreal: International Civil Aviation Organization.
Myers, D. G. (2002) Social Psychology (7th edition). Boston, MA: McGraw-Hill.
Sexton, J.B., & Helmreich, R.L. (2003). Using language in the cockpit: Relationships with workload and performance. In R. Dietrich (Ed.), Communication in High Risk Environments, 57-74. Hamburg: Helmut Buske Verlag GmbH.
American Psychological Association, February 2014