Client Guide

Crew Resource Management

CRM Principles
Why We Do CRM?
Although the role of human error in aviation accidents It also became clear that accidents are rarely the result
has been a subject of study since the 1940’s, it of a single error. Rather, it is usually a chain of events,
wasn’t until the 1970’s that human error was formally known as an error chain that leads to an accident.
addressed.

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 History of CRM Training
1981
United Airlines instituted the first formal Cockpit Resource
Management, or CRM, training program
Late 80’s
• Emphasized changing attitudes about Flight Deck Cockpit Resource Management became Crew Resource
Management. Management.
• Goal was to manage human error through improved
crew performance • Emphasis on the practical application
of CRM skills.

Early 90’s
CRM training expanded to include cabin and cockpit crews, with
formal integration of CRM into checklist procedures. Late 90’s
CRM refocused on its primary purpose the reduction of error.
Error management concepts were introduced.

Present Day
Error management evolves into Threat and error management,
also known as TEM.

CRM Today CRM Skills

CRM is defined as “the use of all available resources to The most impressive result of the implementation of CRM
achieve safe and efficient flight.” is reflected in the fatal accident rate of the airlines- less
than ½ of 1%.
Two questions whose answers make our practice of CRM
more effective: Keep in mind; Crew Resource Management requires a
• What are the resources being managed? continual commitment to improving human factor skills.

• How do I use CRM to achieve safe and efficient

flight?
The use of various CRM skills allows for the effective
management of information necessary to make good
decisions.

NOTES:

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Human Performance and Limitations
Variability of Human Performance
Human performance will vary. To perform a task at a high level of proficiency, where normal variation doesn’t pose a risk,
requires a great deal of practice.

The creation of a whole that is greater than the sum of its parts. People working
well together can do more than the same people working separately.
Synergy
Conversely, people who work poorly together experience negative synergy; they
are less effective working together than if they worked alone.

Occurs when an individual agrees with a group decision, even if they have serious
Groupthink doubts, in order to maintain the benefits of belonging to the group.

Is a tendency for the group to make decisions that are either overly cautious or
Group-polarization extremely risky.

Becomes a concern when decisions are made by a group of individuals

Risky-shift comfortable with risk. Frequently, they will find it easier to make riskier choices as
a group than they do as individuals.

NOTES:

Limitations of Human Performance

Human performance is subject to limitations under the
best of circumstances. The demanding conditions
commonly found in aviation often require the need to
accomplish multiple tasks at the same time.

• Multitasking is possible only under specific

circumstances.
• It’s possible to perform two tasks at the same time,
if the tasks are so well practiced that you don’t have
to think about them.
• Once a task requires conscious thought, your ability
to multitask largely disappears.

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Situation Awareness
Situation awareness (SA): the understanding of what is going on around you.

SA is composed of three levels:

Level 1 - Perception:
Perceiving the environment around you.

Level 2 - Comprehension:
Understanding what has been perceived.

Level 3 - Projection:
Anticipating what happens next, based on what is happening now.

Correctly understanding what is going on gives you the information you need to make good decisions.
The hardest part of SA is correctly perceiving the environment around us.

Studies show that:

• Errors in perception made up 77% of SA errors.

• Errors in comprehension made up 20% of SA errors.

• Only 3% of SA errors occur at the projection level.

SAFE,
Loss of situation awareness markers Recovering SA
Most accidents involve at least four of these red-flags/ What should you do if you lose SA?
markers that indicate a potential loss of situational • Airborne: ensure a safe altitude, stabilize the aircraft

LE ,
awareness:

P
and coordinate with ATC. Asking the questions like

S IM
• Ambiguity “where are we?” “What comes next?” and “Why did
we lose SA?” can help regain SA. Avoid critical
• Fixation phases of flight until SA is regained.

STABLE
• Confusion • On the ground: remain clear of active runways.
• Unexpected change in aircraft state Coordinate with ATC. Consider setting the parking
brake until SA is regained.
• Failure to:
○○ Fly the aircraft (everyone focused on non-flying
activities)
○○ Look outside (everyone heads down)
○○ Meet Targets
○○ Follow SOPs
○○ Comply with limitations, minimums, or regulations
○○ Resolve discrepancies
○○ Communicate fully and effectively

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Communications

Every communication includes a sender and a receiver:

Sender -- Sends message, taking care to make it easily understandable.

Receiver -- Receives message and provides feedback, letting the sender

know that the message was received and understood.

If the message was misunderstood, the sender determines why the communication
failed and adjusts as necessary.

Barriers to communication
Common barriers to communication include:

Environmental
Noisy cockpits Garbled radios

Physical
Hearing Problems Fatigue
Accents Lack of attention

Personal Differences
Gender Age Race
Culture Religion Positions of authority

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Stress Awareness and Mitigation
Effects of Stress on Performance
The Yerkes-Dodson curve plots stress against performance:

High levels of stress = reduced performance

Low levels of stress can reduce performance too. If you Moderate levels of stress have a positive effect on
are too relaxed, it can be difficult to remain alert or even performance, ensuring that you are alert, ready to act
stay awake! when needed but not overwhelmed.

Excessive stress can result in tunnel vision; all of your focus is on a single subject.
In extreme cases, high stress levels can paralyze you, rendering you incapable of any action at all.

Stress Control Techniques

Maintain a stress level that promotes alertness:
• Moving about the cockpit or cabin

• Conversing with crew members

• Reviewing procedures

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Stress Reduction
Stress reduction techniques:
Relax tensed muscles or take a few deep breaths to
get your heart rate under control and increase your
oxygen levels. If you’re unable to keep stress from distracting you,
avoid safety-sensitive duties until the source of stress
Do a very simple task for a short time to get past the is dealt with.
initial physical reaction to an event.

Compartmentalize by putting any thoughts or

feelings not associated with the current task into a
mental box and closing the lid.

Controlling your breathing - taking a few deep

breaths.

Fatigue
The around the clock nature of the aviation industry and
many environmental factors combine to make fatigue an
often cited factor in aviation accidents.

On average, people need 7-9 hours of sleep per night.

Missing as little as an hour of sleep per night can dramatically
affect performance.
Research shows that there is a tendency for pilots to
overestimate their performance when fatigued.

Fatigue Mitigation
The best time to address the effects of fatigue is before
you’re tired. Anticipate fatigue and have a plan to deal with
it:
• Always comply with flight and duty time regulations.

• Utilize fatigue tracking applications that can

determine current alertness levels

• Implement a Fatigue Risk Management system; Use

scheduling software that analyzes schedules to
generate a fatigue risk assessment.

For short-term fatigue mitigation, take a nap!

Limit naps to less than 30 minutes or allow at least 90
minutes for longer naps (to avoid the effects of sleep inertia
or grogginess.)

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Threat and Error Management

Definition of Human Error Violations – Intentional

Errors are “actions or inactions that lead to deviations from Most violations occur due to the expectation that doing
intentions or expectations.” the wrong thing will result in a positive outcome.
Errors can be divided into:
Routine violations are often an attempt to find a more
• Intentional acts: Mistakes resulting from incomplete efficient way to do things. For example, taking a navigational
or erroneous knowledge. shortcut to decrease your workload.

• Unintentional acts: Some routine violations occur when people do not

remember, agree with, or understand why a procedure
○○ Slips: Correctly performing the wrong task.
exists in the first place.
○○ Lapses: Not performing the task at all.
Exceptional violations happen occasionally, and are
also meant to achieve some perceived good,
such as deferring a checklist when confronting an in-flight
emergency.

Theories about Human Error Reporting without retribution

Historically, human error was seen as a problem of the Given an environment where errors can be reported without
individual. A modern view takes into account that people’s fear of retribution, people are more willing to share errors
actions are influenced by their environment. that have occurred, as well as suspected causes and
However, it is probably a little bit of both. If the same error suggestions to prevent future occurrence.
keeps happening, but different people are making it, it For instance, when the Danish government instituted a
makes sense to examine the system in which the errors non-punitive reporting program for their ATC, the number
are occurring. of safety reports went from 15 to 980 during the first year
If, however, a particular individual is making a number of of reporting. Errors already present were finally reported.
different mistakes, then it’s possible that the person is the
source of error.

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Threat Management
The best way to get out of trouble is to avoid it in the first place!

Threat and error management, or TEM, is a strategy that A threat can be external, like weather or traffic, or internal,
recognizes that human error and threats to safety are like an error that the flight crew makes.
inevitable and offers a way to address them. Some threats are obvious, like a line of thunderstorms,
while others may be hidden until the right set of
TEM has two goals: circumstances reveals their presence.
1. Prevent threats and errors from causing an undesired These latent threats are especially difficult to anticipate.
aircraft state. Do your best to avoid the “mitigate” level as some errors
2. Restore safety margins should an undesired state occur. can’t be mitigated!

TEM’s three level pyramid represent lines of defense against Managing the Risk
threats and errors. Risk is a measure of the future impact of a particular set
• Anticipate and Avoid Level: Think ahead to of circumstances:
anticipate threats and plot a strategy to avoid them as • How probable is it that an event will happen?
much as possible.
• How bad will it be if the event happens?
• Detect and Trap level: Catches the errors you
Cross-reference probability against severity on a risk matrix
know will be made- effective monitoring makes this to determine the level of risk, ranging from low to high:
level work.
For example, compare the risk of a wing falling off an aircraft
• Mitigate Level: Seeks to limit the amount of harm (low level risk), to the risk of flying in icing conditions (high
when an error is made and return the aircraft to a level risk.)
desired state.

Risk Relationship Between Probability Severity

Most Probable

High High High Medium Medium

High High Serious Medium Medium

Probability

High Serious Medium Medium Low

Serious Medium Medium Low Low

Least Probable

Medium Low Low Low Low

Low Low Low Low Low

Most Severe Severity Least Severe

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Hazards Acceptable levels of risk
Managing the Risk What is an acceptable level of risk?
Hazards are the source of risk. If you want to determine Risk must be maintained at a level the crew can handle,
how much risk you are facing, start by looking for hazards. and allows for changing conditions that may elevate the
risk level.
Experience or aircraft equipment can change how much
risk a hazard entails. For example, the hazard of a low To manage risk effectively:
cloud ceiling: • Identify hazards present or likely to appear
• Greatest risk: Non-instrument rated pilot
• Identify how those hazards can be expected to
• Less risk: Newly instrument rated pilot change

• Least risk: Experienced instrument pilot • Determine what risk they pose
If you lack sufficient experience to properly evaluate a
hazard, find some help!

Risk Assessment Tool (RAT)

A risk assessment tool (RAT) quantifies the risk posed by factors affecting the operation by assigning point values to
present hazards. When the total risk rises above a certain level, action should be taken to mitigate the risk

Workload Management
Effects of Excessive Workloads Effect of excessive workloads on TEM levels
When you hurry because of excessive workload, you Excessive workload degrades our ability to practice
increase the likelihood of errors and poor task performance. effective Threat and Error Management.

Workload isn’t just defined by the quantity of tasks, but For example, the narrow focus of tunnel vision affects all
also by how much mental effort those tasks require. three levels of TEM:
Sometimes, a single task can result in high workload if • It makes it impossible to think ahead to anticipate and
requires a lot of conscious effort; in contrast, many
avoid hazards.
repeatedly-practiced tasks can require little mental effort.
• It makes the effective monitoring necessary to detect
Managing your workload and trap errors difficult.
The following strategies will help keep workload at a level
• It makes it hard to notice that an error has been
consistent with good TEM:
made, reducing your ability to mitigate the harm the
• Plan ahead
error causes.
• Prioritize tasks by importance to safety

• Delegate when possible

• Slow down when you are hurrying

• Handle one task at a time

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Planning, Monitoring & Distraction Avoidance
Importance of Monitoring NOTES:
In a study done by the US National Transportation Safety
Board, it was found that failure to monitor or challenge
deviations was a factor in 84% of the accidents surveyed.
Every pilot’s primary task is to monitor aircraft flight path.

In the early 2000’s, the term “pilot not flying” was changed
to “pilot monitoring,” emphasizing that the primary task
of the pilot not at the controls is monitoring.

Automation and Monitoring

The increasing complexity and capability of the modern
cockpit poses its own set of monitoring challenges.

How bad are we at monitoring? One study found that:

• Only 40% of pilots noticed a failed glideslope before
beginning an ILS approach. Effective Monitoring
• 30% noticed the failed glideslope after joining the Tips to improve your monitoring performance:
localizer. • Monitor the flight path
• 30% never noticed at all. • Manage your workload
Other monitoring challenges include the design of cockpit
• Plan ahead / Know what to expect
controls and indications, and the fact that many flight crews
are only familiar with the basic, everyday functions of their • Actively Monitor
avionics. Some indications are so rare that by the time you
• Disconnect the autopilot if necessary
see them again, away from training, you’ll have forgotten
what they mean. • Communicate!

Consequences of distraction
The four most reported causes of monitoring errors are
failures to:
1. Cross check flight instruments,
2. Cross-check flight management systems,
3. Verify the mode control panel, and
4. Cross-check charts
Monitoring errors are most common during the descent
phase of flight, followed by climb, approach, and taxi-out.

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Leadership & Followership
In a safety-critical business like aviation, everyone needs to exercise leadership.
Leadership Styles
Authority gradient is a measure of how authority is A shallow authority gradient exists when everyone has
shared. A steep authority gradient, where one person has about the same amount of authority. No one is in charge.
much more authority, serves as a barrier to participation. Shallow authority gradients are undesirable.
Those who lack authority won’t speak up when they know A good authority gradient preserves the command authority
something is wrong, perhaps preferring to hint & hope. of the pilot in command, but encourages others to
participate. You should seek to establish a good authority
There are many ways to exercise leadership. gradient.
Three common leadership styles are:

Authoritarian Democratic Laissez-faire

Steep Authority Gradient Good Authority Gradient Shallow Authority Gradient
Level of Authority

Level of Authority

Level of Authority
Followers Leaders Followers Leaders Followers Leaders

• Leader makes all necessary • Includes followers in the decision- • Allows the followers to
decisions without consultation making process. decide what they want to do

• Assign tasks to followers • Somewhat less efficient than • Lead to very poor
authoritarian at accomplishing tasks effectiveness at completing
• Focuses on the task at hand, not
the necessary tasks.
the social aspects of the group • Leads to greater job satisfaction
• No one is really in charge
• Followers overall job satisfaction • Encourages followers to speak up
may be low when a mistake is made

• Participation of followers may be • Increases the likelihood that errors

limited to doing what they’ve been are trapped
told; risks a reluctance to speak up
if participation is not encouraged.

Effective followership
Effective followers tend to be highly participative, critical A NASA study found that crews with leaders who coupled
thinkers who will speak up and disagree when necessary, a genuine concern for others with a strong drive to do the
share credit, admit mistakes, and habitually exercise job well were consistently more effective and made fewer
superior judgment. errors than crews whose leaders had more negative
Traits of an effective follower: interpersonal traits.

• Self-management
The leader’s foremost responsibility is to ensure
• Commitment
safety of flight!
• Competence Everything the leader does must serve this goal.
• Focus
• Courage
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Conflict Resolution
PACE
Conflicts on the flight deck can distract from the primary
task of ensuring safe flight. Many conflicts can be avoided
by agreeing on standards of action before beginning the
task, resulting in a stronger crew.
Here is an example of a standard agreement:
• Do everything in accordance with your SOP.

• If not up to standard, say something!

• Keep each other advised of what the plan is.

• Don’t do anything that makes us uncomfortable.

PACE stands for:

PROBING Seek an explanation for the captain’s actions

Alert the captain to the loss of safety margins that the current course of action is
ALERTING
causing

Challenge the captain’s actions. State the danger to passengers/crew and

CHALLENGING
demand an alternate course of action.

EMERGENCY WARNING States duty / responsibility to take over control of the aircraft to prevent disaster.

If the emergency warning does not result in the captain

taking action to increase safety margins, then the first
officer will state that they are taking control of the aircraft,
directing the captain to relinquish control.

PACE works best when integrated into company policy.

Organizations must be prepared for such an extreme
scenario if a successful outcome is to be realized.

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Team Building
Purpose of Team Building Strategies for Team Building
Benefits to being part of team: Primary responsibility for effective team building falls upon
• Workload management is easier. the team leader.

• Tasks can be assigned to teammates best-suited to A few simple strategies:

perform them. • Make a good first impression (leader and followers)

• Good teams make fewer errors than bad teams • Emphasize the acceptance of team members.

• More effective handling of demanding situations, • Make clear what is expected of teammates.
even when fatigued • Establish clear lines of, and an expectation of,
communication.

• Provide opportunity for followers to respond

Decision-Making
Decision-Making styles or strategies
People generally make decisions in one of two ways:

Naturalistic (NDM): Optimum (ODM):

• Used in a familiar situations • Used in unfamiliar situations, or when there is
• Doesn’t require a lot of time, can be put into a strong need to make the best possible
action quickly decision.

• Relies on experience and situational • It requires more time to gather information,

awareness: “It’s worked before, and seems consider all the possible options/
likely to work now.” consequences, and pick the option that
provides the maximum benefit.
• A person experiencing stress and/or fatigue
has a greater tendency to use NDM (stress • The goal is to produce the best possible
and fatigue make all decision making styles decision.
less effective, but are especially detrimental
to the SA that makes NDM effective)
• The goal is to produce a decision that’s
“good enough.”

If the decision-maker has poor situation awareness, or lacks experience with the present
situation, naturalistic decision-making can produce very poor results. In these cases, reverting
to optimum decision-making is a better course of action.

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Decision-Making Aids
Practicing with decision-making aids, such as T-DODAR or NMATE, can be of great help when developing your
decision-making skills.
T - Time N - Navigate
D - Diagnose M - Manage
O - Options A - Alternatives
D - Decide T - Take action
A - Act/Assign E - Evaluate
R - Review

Analysis of Decision-making
So how do you know you’ve made a good decision if you
can’t judge the quality of your decisions purely by the
outcome?
Ask yourself:
• Did we follow our SOPs?

• Would we do it that way again?

• How could we have done it better?

• Was the successful outcome the result of luck or a

well-thought out decision?

Post-flight debriefs are the perfect time to ask and answer

these questions.

Briefings and Debriefings

Briefings prepare the crew for the task ahead: Debriefings draw lessons from the day’s
• What is the plan? experiences. The reasons for success and failure are
analyzed so that the next flight can be better.
• What is expected of each crew member? • Never personal or defensive
• What to watch for. • Keep to the facts of what happened, why it happened
and what can be done to improve/continue
performance.
NOTES:

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