CREW RESOURCE MANAGEMENT PDF

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Crew Resource Management Barbara G. Kanki NASA Ames Research Center, Human Systems Integration Division, CA, USA Robert L. Helmreich Professor Emeritus, Dept. of Psychology, University of Texas at Austin, TX, USA Jose´ Anca Swinburne University of Technology, Melbourne, Australia AMSTERDAM • BOSTON...

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Crew Resource Management Barbara G. Kanki NASA Ames Research Center, Human Systems Integration Division, CA, USA

Robert L. Helmreich Professor Emeritus, Dept. of Psychology, University of Texas at Austin, TX, USA

Jose´ Anca Swinburne University of Technology, Melbourne, Australia

AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Academic Press is an imprint of Elsevier

Academic Press is an imprint of Elsevier 525 B Street, Suite 1800, San Diego, California 92101-4495, USA 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 32 Jamestown Road, London NW1 7BY, UK Copyright Ó 2010. Elsevier Inc. All rights reserved Except chapters 5, 14 and 16 which are in the public domain. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone (+44) (0) 1865 843830; fax (+44) (0) 1865 853333; email: permissions@ elsevier.com. Alternatively visit the Science and Technology Books website at www.elsevierdirect. com/rights for further information Notice No responsibility is assumed by the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN : 978-0-12-374946-8 For information on Academic Press publications visit our website at www.books.elsevier.com Typeset by TNQ Books and Journals Pvt Ltd Printed and bound in United States of America 10 11 12 13 14 15 10 9 8 7 6 5 4 3 2 1

Contents Foreword ......................................................................................................... vii John K. Lauber Preface .............................................................................................................. ix Barbara G. Kanki, Robert L. Helmreich and Jose´ Anca PART 1 THE NATURE OF CRM Chapter 1 Why CRM? Empirical and Theoretical Bases of Human Factors Training ............................................................................. 3 Robert L. Helmreich and H. Clayton Foushee Chapter 2 Teamwork and Organizational Factors......................................... 59 Frank J. Tullo Chapter 3 Crews as Groups: Their Formation and their Leadership............ 79 Robert C. Ginnett Chapter 4 Communication and Crew Resource Management ................... 111 Barbara G. Kanki Chapter 5 Flight Crew Decision-Making ...................................................... 147 Judith M. Orasanu Chapter 6 CRM (Non-Technical) Skills d Applications for and Beyond the Flight Deck.......................................................................... 181 Rhona Flin PART 2 CRM TRAINING APPLICATIONS Chapter 7 The Design, Delivery and Evaluation of Crew Resource Management Training............................................................................ 205 Marissa L. Suffler, Eduardo Salas and Luiz F. Xavier Chapter 8 Line Oriented Flight Training (LOFT): The Intersection of Technical and Human Factor Crew Resource Management (CRM) Team Skills ................................................................................... 233 Captain William R. Hamman iii

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Chapter 9 Line Operations Simulation Development Tools ....................... 265 Michael Curtis and Florian Jentsch Chapter 10 Crew Resource Management (CRM) and Line Operations Safety Audit (LOSA) ........................................................... 285 Bruce A. Tesmer Chapter 11 Crew Resource Management: Spaceflight Resource Management .......................................................................................... 301 David G. Rogers Chapter 12 The Migration of Crew Resource Management Training ................................................................................................... 317 Brenton J. Hayward and Andrew R. Lowe PART 3 CRM PERSPECTIVES Chapter 13 A Regulatory Perspective .......................................................... 345 Kathy H. Abbott Chapter 14 A Regulatory Perspective II ....................................................... 361 Douglas R. Farrow Chapter 15 Integrating CRM into an Airline’s Culture: The Air Canada Process.......................................................................... 379 Captain Norman Dowd Chapter 16 The Accident Investigator’s Perspective ................................... 399 Robert L. Sumwalt, III and Katherine A. Lemos Chapter 17 The Airlines’ Perspective: Effectively Applying Crew Resource Management Principles in Today’s Aviation Environment ........................................................................................... 425 Captain Don Gunther Chapter 18 Conversations on CRM from Outside the USA ........................ 435 Jose´ Anca Chapter 19 The Military Perspective ............................................................ 445 Paul O’Connor, Robert G. Hahn and Robert Nullmeyer

Contents

PART 4 CONCLUSIONS Chapter 20 Airline Pilot Training Today and Tomorrow ............................. 469 Captain Linda M. Orlady Chapter 21 The Future of CRM..................................................................... 493 Robert Helmreich, Jose´ Anca and Barbara G. Kanki Index .............................................................................................................. 501

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Foreword

I was privileged to write the Foreword for the 1993 first edition of Cockpit Resource Management. I feel doubly privileged to do the same for this second edition, now re-titled Crew Resource Management, a change that reflects many developments that have taken place in the intervening time. All of us involved in those early days of ‘‘CRM’’ can rightfully feel a sense of pride and satisfaction in what has evolved from an early and comparatively rudimentary set of concepts and practices to nearly universally applied precepts that have significantly improved the way we conduct training and operations in airplanes, ships, medical settings, wildfire management and myriad other previously unimagined applications that involve complex human behavior in organizational and team settings. In 1993, the verb ‘‘to google’’ didn’t exist. When I wrote this Foreword (mid-February 2009), ‘‘googling’’ the term ‘‘crew resource management’’ returned 84,300 results, a number surely to be much larger by the time this book is published. Interestingly, substituting ‘‘cockpit’’ for ‘‘crew’’ in the search term lowered the number of hits by 75% which illustrates how significantly the focus has changed from the cockpit to ‘‘crews’’ in diverse environments that bear little physical resemblance to cockpits, but share a common reliance on complex human performance in a team context for safe and effective functioning. In 1993, the accident rate for global scheduled air transport operations was 1.9 hull loss accidents per million flights; today, that rate is less than 1.0, a major improvement that clearly demonstrates the collective influence of several factors that affect risk and the management of risk in our aviation system. Among these are continued improvements in the design, manufacture and maintenance of transport category aircraft and power plants. Significant improvements in air traffic management, navigation and guidance, and weather detection, analysis and information dissemination also have contributed to vii

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the improved safety picture. Clearly, too, improvements in human performance brought about by the increased understanding and application of the principles of CRM have played a major role in reducing accidents in aviation. Much of this progressive development is attributable to the editors and authors of these two editions, and the work of others whose contributions are described in this volume. In 1993, I used two major air transport accidents to illustrate the reduction of risk in airline operations made possible by the early introduction of CRM conceptsdthe 1972 Lockheed L-1011 accident in the Florida Everglades, and the 1989 McDonnell Douglas DC-10 accident at Sioux City, Iowa. The first accident claimed the lives of all 163 passengers and 13 crewmembers after the flight crew became distracted while changing a burned-out indicator light and allowed the aircraft to descend into the swamp. In the second accident, nearly two thirds of the total of 296 passengers and crew survived in large part because the crew successfully applied the principles of CRM to manage what otherwise would have been a non-survivable event due to total loss of flight controls. As I write this Foreword, only a few weeks have passed since what some have termed ‘‘the Miracle on the Hudson.’’ All passengers and crew survived the ditching of an Airbus A320 in the Hudson River due to a double engine failure consequent to multiple bird strikes shortly after takeoff. Although the NTSB report on this accident is many months away, it appears that what could have been a major disaster for those aboard, and potentially many on the ground, was instead a tale of what went right. In no small part this outcome was due to the exquisite management of all available resources by the cockpit and cabin crewmembers and by the ground forces that responded to the ditching. Again, the fortunate outcome of this event represents the confluence of many factors, but it is very clear that none of those would have made much of a difference had the flight crew not executed a successful ditching, and, subsequently and in close concert with the cabin crew, evacuated all 155 persons on the aircraft. This accident seems to represent the highest form of human performancedCRM at its very best. In 1993, I concluded ‘‘(CRM) is an exciting story, and one which offers great personal gratification. There are few more rewarding efforts than those which result in the saving of lives.’’ In the intervening years, the exciting story and its then only imagined benefits have generated nearly universal application of CRM principles in virtually thousands of settings. This is a direct result of evolutionary developments in concept and practice honed by a multitude of dedicated researchers and practitioners. Still, it remains a story of enormous personal gratification and rewarddcountless lives have undoubtedly been saved by the collective efforts of those whose works are chronicled here. John K. Lauber Vaughn, WA

Preface

In 1993, Cockpit Resource Management (CRM) was celebrated as the convergence of a concept, an attitude and a practical approach to pilot training. Equally important was the convergence and enthusiastic support of the research community, aviation regulators, transport operators and pilot organizations. CRM was maturing, implementing and continuing to develop all at the same time. It was always said that if CRM succeeded, it would disappear as stand-alone training as it became fully integrated into an airline’s training program. As early as 1990 the Federal Aviation Administration (FAA) provided a mechanism for achieving just that, in the form of the Advanced Qualification Program (AQP). But CRM grew in many other directions as well. Fifteen years later, CRM concepts have endured not only by disappearing into the fabric of training, but by expanding the team concept, evolving into new applications and now integrating itself into an even higher level of safety and quality assurance goals. Even in 1993, it was evident that CRM was being applied beyond the cockpit and we acknowledge that CRM more appropriately stands for Crew Resource Management. While we will continue to focus on CRM in the cockpit in this edition, we want to emphasize that the concepts and applications provide generic guidance and lessons learned for a wide variety of ‘‘crews’’ in the aviation system and in the complex, highrisk operations of many non-aviation settings. In the late 1970s, when our late colleague H. Patrick Ruffell Smith launched his classic study of flight crew performance in a Boeing 747 simulator, he could not have dreamed of what would be inspired by that project. The experiment originally investigated pilot vigilance, workload and response to stress. What is a great testament to that ix

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early research is that we continue to make effective use of the simulator to investigate vigilance (situational awareness), workload management and response to stressdand a host of human factors affected by the continually evolving airspace system. Ruffell Smith opened the door to researching human factors and to a useful methodology for assessing crew performance as well as the reliability of instructor and evaluator judgments. CRM training, like any new approach to a well-established, tradition-bound enterprise, was not universally acclaimed in its early years. Many airline managers dragged their feet; they claimed that they were doing it anyway, just not under the name of CRM. And besides, who had any proof that the new training was effective? The FAA viewed the field with a degree of skepticism in the beginning, in spite of a string of recommendations from the National Transportation Safety Board (NTSB) that CRM training be required of the nation’s airlines. In our original 1993 edition of Cockpit Resource Management, it was clear that momentum was taking hold, not only in US commercial aviation, but in the military and abroad. While AQP was still under development, US and international operators, pilot organizations, investigators, regulators, researchers and others in the industry became an active CRM community that experimented with training approaches and shared its results. In the spirit of its successful collaboration, this edition incorporates a mixture of US and non-US researchers, operators and regulators; our authors personally remember the beginnings of CRM and helped to support and develop new directions and refinements to build what CRM is today. Crew Resource Management, 2nd Edition, consists of three main sections: (1) Nature of CRM, (2) CRM Training Applications and (3) CRM Perspectives. A short final section, Conclusions, provides summary observations about the current state-of-the-practice and thoughts of the future. Following are brief descriptions of three main sections. Part 1: Nature of CRM contains an introduction and discussion of familiar CRM concepts and skills, such as the teamwork, communication and decision-making. Much of the original research and early initiatives are preserved in these pages and it is exciting to see how far the concepts have grown, not just from a theoretical perspective but how they have matured into useful training methods and expanded in directions we had not imagined. Part 2: CRM Training Applications contains chapters that describe some of the many innovations that have grown from CRM training. It introduces tools that support CRM training development and performance assessment as well as audit tools that are used in line operations. While there are numerous examples of CRM adapted to other airline teams (e.g. maintenance, flight attendants, dispatch), and to teams outside

Preface

aviation (e.g. spaceflight, medical, rail), there are too many to cover them all. However, we devote a couple of chapters to review some of these developments. Part 3: CRM Perspectives consists of chapters that illustrate the impact of CRM when implemented. While flight training departments in both commercial and military transport operations were the original practitioners of CRM training, concepts and skills were adopted in many countries and also influenced the way in which regulators and investigators understood and analyzed human performance. This section discusses some of these perspectives and describes a few of the many ways CRM is implemented in different airline/transport cultures. Although the basic CRM topics in Part 1 have a generic quality, Part 3 shows how common topics are tailored to fit different organizations. Corresponding to the breadth of CRM topics, applications and perspectives, we write to a global audience including aviation training practitioners, managers, corporate decision-makers, regulators, investigators and researchers. In addition, we hope that other airline departments, as well as non-aviation industries, will find topics of interest and usefulness in developing CRM tools and programs for their own work settings. We believe CRM presents a success story as it has transcended its own training roots and followed a path of adaptation and expansion that addresses larger, safety management objectives. It is a model whichdin spite of cultural barriers, economic setbacks and bureaucratic complexitiesdhas become a household word in aviation. We thank our authors for a job well done and for helping to preserve this documentation of CRM history and lessons learned. In addition, we are grateful to the staff at Elsevier for their very professional help and encouragement. Finally, we dedicate this volume to the thousands of flight crews throughout the world whose participation and experiences continue to provide the reason that CRM succeeds. Barbara G. Kanki Robert L. Helmreich Jose´ Anca

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PART 1

The Nature of CRM

Chapter 1

Why CRM? Empirical and Theoretical Bases of Human Factors Training Robert L. Helmreich Department of Psychology University of Texas at Austin Austin, Texas 78712 H. Clayton Foushee y Senior Professional Staff, Oversight and Investigation, Committee on Transportation and Infrastructure, U.S. House of Representatives

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Prior position: Northwest Airlines St. Paul, Minnesoto 55111.

Crew Resource Management Copyright Ó 2010, by Elsevier Inc. All rights of reproduction in any form reserved.

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Chapter 1 • Why CRM? Empirical and Theoretical Bases of Human Factors Training

Introduction Section 1.1 of this chapter is the introductory chapter of the 1993 edition of the book. This reprint is important for the reader because it covers the antecedents and history of CRM from 1978 until 1992. Some of the predictions for the future of CRM have been borne out while others have not. Fifteen years ago, CRM was not universally accepted by the pilot community: it was sometimes decried as charm school, psychobabble, and attempted brainwashing by management and some of these criticisms had merit. The evolution of CRM is covered through its third generation. Section 1.2, CRM Redux, covers the fourth, fifth and the current sixth generation which focuses on the threats and errors that must be managed by crews to ensure safety in flight.

1.1. The Evolution and Growth of CRM 1.1.1. Introduction One of the most striking developments in aviation safety during the past decade has been the overwhelming endorsement and widespread implementation of training programs aimed at increasing the effectiveness of crew coordination and flightdeck management. Civilian and military organizations h...