Making Air Travel Safer Through Crew Resource Management (CRM)

CRM has prevented accidents and saved lives in the aviation industry - and soon may save lives in hospital operating and emergency rooms. Findings In the 1970's investigators discovered that more than 70% of air crashes involve 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 consist of failures in leadership, team coordination, and decision-making. The response of the aviation community was to turn to psychologists such as John K. Lauber and Robert Helmreich 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 now known as Crew Resource Management (CRM). Dr. Lauber, a 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, it is the active process employed by crew members to identify existing and potential threats and to develop, communicate, and implement plans and actions to avoid or mitigate perceived threats. CRM supports the avoidance, management, and mitigating of human errors. The secondary benefits of effective CRM programs are improved morale and enhanced efficiency of operations. As part of the validation of the behavioral impact of CRM training, Dr. Helmreich and colleagues at the University of Texas Human Factors Research Project developed an observational process, the Line Operations Safety Audit (LOSA) to assess both CRM practices and management of the threats to safety and inevitable human error that accompany complex flight operations. In LOSA, expert observers ride in the cockpit on regularly scheduled flights under conditions of strict confidentiality and record not only CRM practices but also the many threats in the operational environment and their management and the nature and management of crew errors. The fact that a number of violations of formal rules are observed confirms that crews accept the confidential nature of the observations. Significance CRM alerted the aviation industry to the human-to-human interactions that are an integral part of any team performance. This training has the potential to save lives and money, and prevent accidents and lawsuits as well. While no one can assess how many lives have been saved or crashes averted as a result of CRM training or safety initiatives based on data from LOSA, the impact has certainly been significant. LOSA data demonstrate that 98% of all flights face one or more threats, with an average of 4 per flight. Errors are also observed on 82% 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, certainly 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, training and safety initiatives can be made more effective. A real-world example of how CRM may have saved lives can be found in psychologist David Myers’ Social Psychology textbook, comparing two airline crashes in the 1980’s: Helmrich (1997)…notes that flawed group dynamics were evident when an Air Florida plane lifted off from Washington's 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, which 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. Practical Application Crew Resource Management training is now required for airlines in 185 countries by the International Civil Aviation Organization (ICAO), the regulatory component of the United Nations. The medical community is also responding to findings of human error and failures by adapting aviation’s approach to crew coordination. It is initiating psychological training that conceptually parallels CRM and crisis management. The Agency for Healthcare Research and Quality is supporting research at The University of Texas at Austin to apply safety practices and training concepts proven successful in aviation to medicine, particularly in operating and emergency rooms. CRM training is also being used in 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. Cited Research 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, Vol. 3, No. 2, pp. 121-129. Helmreich, R.L. (in press). 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 (pp. 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 (pp. 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 (pp. 57-74). Hamburg: Helmut Buske Verlag GmbH. Additional Sources University of Texas Human Factors Research Project Website: http://www.psy.utexas.edu/HumanFactors American Psychological Association, February 6, 2004 For more on Safety, click here. For more on Decision Making, click here. For more on Workplace/Industry, click here.

Glossary of Psychological Terms