HUMAN FACTORS IN FLIGHT

Crew Resource Management, Crew Coordination, In Relation to Aircraft
Accidents
By R. Jason Dagenhart
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Abstract
In this paper you will learn how Crew Resource Management came into effect
and the reasons behind the need of CRM to further prevent accidents from
happening. I will discuss the Communication aspect of CRM, how Crew
Coordination is a very important program for multi-crew cockpits, and
should be taken very seriously. Finally, I will present some examples of
what happens when a break down in CRM and Crew Coordination occurs, and how
most often the result is disastrous.


Crew Resource Management
CRM is a process designed to aid in the prevention of aviation
accidents and incidents by improving crew performance through a better
understanding of human factor concepts. It involves the understanding of
how crewmembers’ attitudes and behaviors impact safety. They identify the
crew as a unit of training, and provide an opportunity for individuals and
crews to examine their own behavior and make decisions on ways to improve
teamwork.

The evolution of CRM came from investigations into air carrier
mishaps. They show since 1970 that human error is a contributing factor in
60 to 80 percent of all incidents and accidents (National Civil Aviation
Review Commission). Human error is the action, reaction, and decision of
the individual. Their errors cause most accidents, not catastrophic
failures of operating systems. Research has discovered that these events
are attributed mostly to problems associated with poor group decision-
making, ineffective communication, inadequate leadership, and poor task or
resource management. In 1986, the assembly of the International Civil
Aviation Organization (ICAO) adopted a resolution on flight safety and
human factors. It stated that in order to improve safety in aviation;
operators must be made more aware and responsive to importance of human
factors in aviation through proactive learning and from the reactions of
others. As a result, the National Transportation Safety Board (NTSB)
recommended implementing CRM training for all crewmembers.

CRM is but one practical application of Human Factors. Although CRM
can be approached in many different ways, there are some essential
features. The focus on the functioning of the flight crew as an intact
team, not simply as a collection of technically competent individuals; and
should provide opportunities for crew members to share their skills
together in roles they normally perform in flight. CRM should teach crew
members how to use their own personal and leadership styles in ways that
foster crew effectiveness. It should also teach crew members that their
behavior during normal, routine circumstances can have a powerful impact on
how well the crew as a whole functions during high-workload and stressful
situations. During critical emergency situations, basic skills and
knowledge come into play, and it is unlikely that any crew member will be
able to take the time to reflect upon his or her CRM training to determine
how to act. Similar situations experienced in training increase the
probability that a crew will handle actual stressful situations more
competently.

With the new and ever advancing aircraft CRM is essential in the
aviation world today. Now that you have a better understanding on how CRM
works, let’s focus in on the communication aspect of CRM.


Crew Coordination
An analysis of aviation accidents revealed that a significant
percentage of accidents resulted from one of more crew coordination errors
committed before or during a flight. Often an accident was the result of a
sequence of undetected crew errors that combined to produce a catastrophic
result. Additional research showed that even when accidents are avoided,
these same errors can result in degraded flight performance. Aircrew
coordination is the interaction between crew members necessary for the
efficient and effective performance of tasks.

There are eight elements (provided by the United States Army Crew
Coordination program) to be used to achieve maximum performance of crew
coordination.

1. Communicate Positively. Good cockpit teamwork requires
positive communication among crew members. Communication is
positive when the sender directs, announces, requests, or
offers information; the receiver acknowledges the
information; the sender confirms the information, based on
the receiver’s acknowledgment or action. The receiver must
anticipate what the sender says or wants and listen
carefully. Either crew member must have no doubt what is
said or meant prior to taking action.

2. Direct Assistance. A crew member will direct assistance when
he cannot maintain aircraft control, position, or clearance.

He/she will also direct assistance when he/she cannot
properly operate or troubleshoot aircraft systems without
help from the other crew members.

3. Announce Actions. To ensure effective and well-coordinated
actions in the aircraft, all crew members must be aware of
the expected movements and unexpected individual actions.

Each crew member will announce any actions that affect the
actions of the other crew members
4. Offer Assistance. A crew member will provide assistance or
information that has been requested. He/she also will offer
assistance when he/she sees that another crew member needs
help.

5. Acknowledge Actions. Communications in the aircraft must
include supportive feedback to ensure that crew members
correctly understand announcements or directives.

6. Be Explicit. Crew members should use clear terms and phrases
and positively acknowledge critical information. They must
avoid using terms that have multiple meanings. Crew members
must also avoid using indefinite phrases.

7. Provide aircraft control and obstacle advisories. Although
the pilot is responsible for aircraft control, the other crew
members may need to provide aircraft control information
regarding airspeed, altitude, or obstacle avoidance.

8. Coordination action sequence and timing. Proper sequencing
and timing ensure that actions of one crew member mesh with
the actions of the other crew members.

By utilizing these eight elements flight crews will successfully
communicate and resolve issue that can rise in a cockpit. They will also
help reduce the number of accidents that occurred do to human error.

Flight team leadership and crew climate are established and maintained
by the positive atmosphere of the cockpit. The relationships among the crew
and the overall climate of the flight deck are important to the safety of
flight. Aircrews are teams with a designated leader, whose lines of
authority and responsibility are clear. The pilot sets the tone for the
crew and maintains the working environment. Effective leaders use their
authority but do not operate without the participation of other crew
members. When crew members disagree on a course of action, they must be
effective in resolving the disagreement.

Here are some goals for a pilot to achieve the overall positive
atmosphere of the cockpit.

a. The pilot should actively establish an open climate where the
crew members freely talk and ask questions.

b. Crew members value each other for their expertise and
judgment. They do not allow differences in rank and
experience to influence their willingness to speak up.

c. Alternative viewpoints are a normal yet occasional part of
crew interaction. Crew members handle disagreements in a
professional manner, avoiding personal attacks or defensive
posturing.

d. The pilot actively monitors the attitudes of crew members and
offers feedback when necessary. Each crew member displays
the proper concern for balancing safety with flight
performance.


Communication has often failed in the cockpit because the person in
charge, the flight-deck captain or pilot, did not listen to junior crew
members regarding possible erroneous control inputs, misinterpretation of
flight information, or needed changes in attention. Sometimes the junior
officers, or person of equal status for that matter, withheld vital
information to the safety of flight, but did not pass that information to
the pilot in command because of the intimidation the junior pilot has
towards the much more senior captain. In one case the captain told the co-
pilot to “just look out the damn window”, when challenged several times
about holding a prescribed altitude (Foushee, 1982).

Here are some case examples of accidents where a break down in CRM and
crew coordination lead to mishaps. This first example is a perfect display
of not utilizing your crew to its potential in assigning everyone a task to
successfully working a problem out. Everglades-AN L-1011 crashed in the
Everglades because the entire crew was focused on a possible landing gear
problem. In reality, the problem was nothing more than a burned-out bulb
(landing gear indicator light). While the crew’s attention was diverted,
the autopilot was apparently accidentally disengaged, and the plane made a
gradual descent into the ground. A key aspect of this mishap was a radio
transmission from a controller, who knew of the indicator light problem.

The controller asked, as the aircraft was descending to a dangerously low
altitude, “How are things coming along out there?” The crew and 99
passengers perished. A more direct communication should have been, “watch
you altitude”, may have prevented this horrible mishap. I suspect that if
the captain had either himself or assigned the first officer to fly the
plane while the rest of the crew dealt with the problem of the light the
accident wouldn’t have taken place. CRM was created to prevent mishaps
like this one from happening.

This next accident is similar to the pervious accident where the crew
was focused in on light, but the break down in crew coordination lead to
the unnecessary death of passengers. Portland-a DC-8 crashed a few miles
from the runway, after running out of fuel. This too occurred as the crew
was concentrating on a landing-gear warning light. The captain (who
survived) indicated that he wanted to leave enough time for the flight
attendants to get “crash ready”. The flight engineer, who repeatedly told
the captain that fuel was very low, died in the crash. The problems of
communication failure and break-down in crew coordination mainly on the
captain are a good example of rank differences. The higher ranks thinking
that I know what I’m doing and not utilizing the crew to work through
problems. A breakdown in crew performance had caused over 60 mishaps in a
10-year period.

The KLM accident in Tenierife was a prime example of what shouldn’t be
allowed into a multi-crew cockpit. The elements of being irritated, not
patience and using expectancy of what to the captain wanted to here lead to
the death of three hundred and thirty five people. First officers should
always be more assertive with the captain when it comes to flight safety,
don’t be intimidated.

The PanAm flight had to wait for almost two hours before all KLM
passengers had reloaded and refueling had taken place. The KLM flight was
then cleared to backtrack runway 12 and make a 180 degree turn at the end.

Three minutes later Pan Am 1736 was cleared to follow the KLM aircraft and
backtrack runway 12. The PanAm crew was told to leave the runway at the
third taxiway and report leaving the runway. KLM 4805 reported ready for
take-off and was given instructions for a papa beacon departure. The KLM
crew repeated the instructions and added “We are ready for take-off”. The
brakes were released and KLM 4805 started the take-off roll. Tenerife
tower, knowing that PanAm 1736 was still taxing down the runway replied,
“Ok stand by for take-off, I will call you.” This message coincided with
the PanAm crew’s transmission “No we’re still taxiing down the runway, the
Clipper 1736″. These communications caused a shrill noise in the KLM
cockpit, lasting approx. 3.74 seconds. Tenerife tower replied: “Papa Alpha
1736 report runway clear”. Whereupon the PanAm crew replied: “Ok, will
report when we’re clear”. This caused some concerns with the KLM flight
engineer asking the captain: “Is he not clear then?” After repeating his
question the captain answered emphatically: “Oh, yes”. A number of seconds
before impact the KLM crew saw the PanAm Boeing still taxiing down the
runway. The crew tried to climb away and became airborne after a 65ft tail
drag in an excessive rotation. The Pan Am crew immediately turned the
aircraft to the right and applied full power. The KLM aircraft was
airborne, but the fuselage skidded over the PanAm’s aft fuselage,
destroying it and shearing off the tail (Aviation Safety Network). If the
captain had not been in a rush to get out of Tenerife and listen to the
first officer and flight engineer, this accident could have been prevented.

It proves that when a person on a flight crew suspects something to be
wrong, they must be assertive and speak up. The aircraft shouldn’t move or
change position until everyone is comfortable with the situation.

CRM and Crew coordination are two very important programs that the air
industry has taken hold and provided extensive training for all of its air
crews. As long as human operators are in the cockpit, there will always be
a need to have management skills and communication standards. These need
to be met by each and every person who resides in an aircraft flight deck.

References
Aviation Safety Network: http://aviation-safety.net/database1977/770327-
1htm
Crew Resource Management: Department of the Air Force
Air Force Flight Standards Agency
AT-M-06A December 1998
Crew Coordination: United States Army
http://www.stricom.army.mil/OPS/FSXXI/oh58/DraftATM/TC%201-
248%20Chap%206…


Navy and Marine Safety School
Chapter Nine: Aviation Psychology and Human Factors
Communications and Crew Coordination
Dr. Anthony Ciavarelli
emailprotected
Human Factors in Air Safety
(July 17, 2000)
Dr. Anthony P. Ciavarelli
School of Aviation Safety
Naval Postgraduate School, Monterey California